Lifestyle and Nutritional Assessment Form

Lifestyle and Nutritional Assessment Form

Dear Client: Please read the instructions of each form carefully and complete this questionnaire with care. Your answers will help me determine the most effective recommendations to make based on your main health concern(s) presented. This health history record is protected and kept strictly confidential. It will not be released without your consent.

Name: ______

Date: ______

Telephone (Home): ______

(Work): ______

(Cell): ______

Email: ______

Age: ______

Height: ______

Weight: ______

Sex: M F

Appointment Reminders? No Email Phone AHS Quarterly Newsletters? Yes No

Please answer each question carefully and LEAVE BLANK those that don’t apply to you.

LIFESTYLE:

What is your #1 goal you want to achieve during our time together______

______

What are your main health concerns?Please list concerns in priorityand when they started:

1. / 4.
2. / 5.
3. / 6.

Have you ever experienced any major trauma? ______

What level of stress do you currently experience?Please quantify on a scale of 1 (low) to 10 (high):____

What are the major causes of your stress? ______

How does your stress manifest (show)? ______

What coping mechanisms do you implement? ______

Do you vacation regularly? Yes No What was your last vacation? ______

What is your current exercise routine? (Include type, frequency and duration) ______

______

Are you satisfied with your present weight? Yes No

Do you wish to gain weight? lose weight? If so, how much? ______

How would you describe your energy levels on a scale of 1 (low) to 10 (high)?______

Do you experience any lulls or highs in energy levels throughout the day? Yes No

If so, what time(s) of day? ______

How many hours on average do you sleep daily? ______

Do you: have difficulty falling asleep? Staying asleep? Awaken feeling unrested? Snore?

What is your occupation? ______

What do you enjoy/not enjoy about work? ______

______

How many hours each week do you work? ______Do you work shifts? Regular schedule?

Do you smoke? Yes No If yes, how much and for how long? ______

Are you ever exposed to smoke at home or at work? Yes No

Do you use recreational drugs? Yes No If yes, please describe:______

Have you ever been treated for: drug dependency? Alcohol dependency?

How many hours do you spend daily, on average:

Driving? ______

Watching TV? ______

Reading? ______

Ona computer? ______

Sitting at a desk? ______

What isyour currentmorning/eveningroutine? ______

______

What are your interests and hobbies? Please list: ______

How much free time do you feel you have in a day? ______

If need be, how would you make more time for yourself? ______

Do you regularly check in with yourself (self-reflect)? Yes No Need reminders to do so

Time permitting, what would you like to incorporate into your day? ______

______

MEDICAL HISTORY:

Are you currently taking medication (including birth control)? Yes No

Name of Prescription Medication / Reason(s) for Medication / Duration of Medication

Have you taken antibiotics over the past 5 years? Yes No

If yes, when werethey last taken and the reason for taking it? ______

______

Are you currently taking Natural Health Products (NHPs)? (Includes vitamins, minerals, herbs and homeopathic remedies) Yes No

Name of NHP / Reason(s) for NHP / Daily Amount/Dose

Do you have any allergies or sensitivities (includingto medication)? Yes No

If so, please list: ______

Are you anaphylactic (life-threatening allergy)? If so, to what: ______

Do you have any silver-mercury fillings? Yes No

If so, how many and for how long? ______

Do you have any root canals? Yes No If so, how many and for how long? ______

Have you ever been a) Diagnosed with an illness? Yes No If so, please explain: ______

______

b) Hospitalized? Yes No If so, for what reason: ______

Have you had surgery to remove your gall bladder? Tonsils? Appendix?

If so, explain: ______

Have you experienced fungal infections (Ex. Jock itch, Athlete’s foot)? Yes No

If so, please describe: ______

Have you experienced a decline in sexual interest? Yes No

Have you had kidney stones or gallstones? Yes No If yes, please describe: ______

How often do you have a bowel movement daily? ______

Do you strain to have a bowel movement? Yes No Occasionally

Related to particular food or circumstance? ______

Do you have loose bowel movements? Yes No Occasionally

Related to particular food or circumstance?______

Is there undigested food in your stools? Yes No Occasionally

Other bowel-related concerns? (Colour, blood, oily, etc.) ______

FAMILY HISTORY:Use “F” for father, “M” for mother, “S” for sibling, “G” for grandparent, “O” for other(s):

Allergies / Diabetes / Intestinal Disease
Alcoholism / Drug Abuse / Kidney Dysfunction
Arthritis / Gall Bladder Issues / Mental Illness
Asthma / High Cholesterol / Osteoporosis
Autoimmune Disease / Heart Disease / Skin Conditions
Cancer / Hypertension / Ulcers
Type(s) of Cancer: / Other condition(s):

FEMALES:

Are you pregnant? Yes No Are you currently breastfeeding? Yes No

Have you noticedany changes in menses? (Ex. Frequency, duration, flow, clotting, etc.) Yes No

If so, please specify: ______

Do you suffer from PMS symptoms? Please specify: ______

Are you pre-menopausal? Yes No Post-menopausal? Yes No

Are you experiencing any menopausal symptoms? Yes No

If yes, please specify: ______

Have you had a bone density test? Yes No If yes, what was the result? ______

MALES:

Have you experienced any prostate problems? (Ex. frequent urination, discomfort during urination)

Yes No If yes, please describe: ______

NUTRITIONAL AND DIETARY HABITS:

How many times a day do you eat, on average?

Main meals: ______Times of day: ______

Snacks: ______Times of day: ______

Provide examples of your typical meals and snacks:

Breakfast: ______

Lunch: ______

Dinner: ______

Snacks: ______

Do you eat: With family? Home alone? On the run? Restaurant? Fast food?

Where do you commonly grocery shop? ______

What percentage of meals/snacks consumed are homemade? ______

In terms of preparing your own meals, what is your skill level in the kitchen? Please quantify on a scale

of 1 (low) to 10 (high):______

How many servings of each food type do you typically consumein a day?

______FruitFresh Frozen Canned Dried

______VegetablesCooked Raw Frozen Canned

______Whole GrainsType: ______

______ProteinType: ______

______DairyType: ______

______FatsType: ______

______OtherType(s): ______

Do you eat or use (indicate “1” for “rarely”, “2” for “regularly”, “3” for “often”):

______Aluminum pans

______Artificial Sweeteners

______Candy

______Cigarettes

______Refined Foods (pastries, white pasta, etc.)

______Fried Foods

______Luncheon Meats

______Margarine

______Microwave

______Fast Foods

Please indicate how many cups of the following you drink per day:

______Tap water

______Coffee

______Tea

______Soft drinks (diet)

______Soft drinks (regular)

______Fresh fruit juices

______Fruit juices (prepared)

______Milk

______Prepared vegetable juices

______Fresh vegetable juices

______Red wine

______White wine

______Beer

______Other alcoholic beverages

______Bottled or spring water

______Herbal tea

______Other: ______

Do you currently follow a special diet? Yes No If yes, please explain: ______

______

Do you avoid certain foods? Yes No If yes, list food(s) and reason why: ______

______

How often do you eat meat?Daily 3-5/week Once/week or less

How often do you consume dairy?Daily 3-5/week Once/week or less

What’s your favourite food(s) and how often do you eat them? ______

______

Which food(s) do you crave, and how often do you eat them? ______

______

Do you experience any symptoms of meals are missed? Yes No

Please explain: ______

Do you experience any symptoms after meals? Yes No

Please explain: ______

COMMENTS:______

______

Nutri-System Profile (NSP) Assessment Form

Please indicate if you’re experiencing any of the symptoms or activities below by indicating:1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.

General fatigue or weakness / Varicose veins
Difficulty losing weight / Feeling out of control
Frequent illness/infections / Food/chemical sensitivities
High stress lifestyle / Frequent yeast/fungus problems
Smoking / Bones break easily, osteoporosis
Drink more than 2 cups of coffee/day / Too little exercise
Bad breathe and/or body odour / Excessive mucous
Constipation / Shortness of breath climbing stairs
Bags under eyes / Tingling in lips, fingers, arms, legs
Craves sugar, bread, alcohol / Chest pains
Difficulty digesting certain foods / Very rapid or slow heart beat
Recent antibiotic use / Painful, hard or thin bowel movements
Allergies / Alternating constipation/diarrhea
Poor concentration or memory / Recurrent bladder infections
Belching or burping after meals / Female: Menopause, hot flashes
Skin/complexion problems / Female: PMS
Frequent consumption of red meat / Difficult urination
Regular use of dairy products / Swollen glands, puffy throat
Heavy alcohol consumption / Lower abdominal pain
Exposure to toxins/chemicals / Frequent need to urinate
Frequent mood swings / Joint pain
Depressed and/or irritable / Sinus inflammation/discharge
Brittle fingernails / Arthritis
Dry, brittle hair, split ends / Sudden weight gain/loss
High fat/high cholesterol diet / Headache/Migraines
Nervousness/anxiety/tension/worry / Female: Taking birth control pills
Insomnia, restless sleep / Lower back pains
Low fiber diet / Dry, flaky skin
Muscle cramps / Drink less than 6 glasses of fluid/day
Sleepy when sitting up / Water retention
Female: menstrual cramps / Low sex drive
Bronchitis/asthma//pneumonia/emphysema / Feeling heavy/bloated after meals
Cellulite / Chronic cough
Cold hands and feet

COMMENTS: ______

______

PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM:1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.

THE DIGESTIVE SYSTEM

Excessive gas, belching or burping after meals / Full feeling after heavy meat meal
Stomach bloated after eating / Heavy, tired feeling after eating
Sleepy after eating / Nausea after taking supplements
Longitudinal striations on fingernails / Acne
Eat when rushed/in a hurry / Undigested food in the stool
Bad breathe
Stomach pain 1 hour after eating or at night / Sensation of acidity in abdominal area
Burning sensation in stomach / Heartburn, indigestion
Pain aggravated by worry/tension / Blood in stool
Hiatal hernia / Lower back pain
Gastritis, gastric ulcer / Long term aspirin use
Nausea, vomiting
Yellow or pale fingernails / Food allergies
Skin oily on nose and forehead / Irritable, easily angered
Fats/greasy foods cause nausea, headaches / Weight gain around the abdomen
Vertical white streaks on fingernails / Yellow palms
Onions, cabbage, radishes, cucumbers cause bloating/gas / Jaundice
Bad breathe; bad taste in mouth / Poor concentration
Excess body odour / Difficulty losing weight
High cholesterol/high cholesterol diet / Acne, boils, rashes, psoriasis or eczema
Migraine headaches / Constipation
Discomfort underneath right ribcage
Gall stones; history of gallstones / High cholesterol diet; high blood cholesterol levels
Stool appears clay-coloured, foul odoured / Severe pain in right upper abdomen
Constipation
Severe abdominal pain / Fever
Nausea and vomiting / Alcohol addiction
Slow digestion; feel full for hours after eating / Jaundice
Hungry up to 3 hours after eating / Family history of diabetes
Strong cravings for sweets, starches, coffee or alcohol / Fatigue
Nervous/anxious feelings relieved by eating / Frequent headaches
Irritable if late for or skip a meal / Fainting spells
Overweight / Depression
Addicted to pop and/or coffee with sugar / Lose temper easily
Frequent “midnight snacks”

THE INTESTINAL SYSTEM

Extreme fatigue / Rectal itching
Recurrent vaginal infections / Abnormal muscle aches from exercise
Frequent use of antibiotics / Excessive wax in ears
White coated tongue, oral thrush / Unexpected/unexplained weight gain
Craves sugars, bread, alcohol / Impotence
Headaches / Canker sores
Tonsillitis, recurrent strep throat / Athlete’s foot, finger/toenail fungus, ringworm
Itchy, watery or dry eyes / Jock itch
Skin flushes / “Brain fog”
Chronic indigestion, frequently use antacids / Irritability
Always cold, especially in extremities / Memory loss
Female: PMS / Mental confusion
Pain in pelvic area / Depression or anger for no reason
Abdominal gas and bloating / Anxiety/panic attacks
Loss of sex drive / Inability to concentrate
Cystitis, repeated bladder infection / Phobic/compulsive
Increasing food and chemical sensitivities / Lethargy
Female: Endometriosis/ ovary problems / Mood swings
Chronic diarrhea / Itchy ears, nose, anus
Hives, psoriasis, acne, skin rashes
Forgetfulness / Pain in the back, thighs, shoulders
Slow reflexes / Numb hands
Gas and bloating / Drooling while sleeping
Unclear thinking / Damp lips at night
Loss of appetite / Dry lips during the day
Yellowish or pale face / Grind teeth while asleep
Fast heartbeat / Bedwetting
Heart pin / Lethargy; chronic fatigue
Pain in navel / Dark circles under eyes
Eating more than normal but still feeling hungry / Cancer
Blurry or unclear vision / Rectal itching

THE LYMPHATIC SYSTEM

Excessive sleep / Soreness on both sides of neck at shoulder
Very susceptible to infections / Feel puffiness in throat
Swollen glands: tonsils, throat, armpits / Look older than chronological age
History of cancer, MS, Parkinson’s, arthritis / Flu-like symptoms often occur
Loss of appetite / Lupus
Headaches

Acne, psoriasis, dermatitis, eczema / Excessive sweating, night sweats
Rapid pulse, heart irregularities / Bowel disease: IBS, IBD, Crohn’s, etc.
Frequent headaches / Joint pains or stiffness
Hay fever / Frequent night urination
Frequent cravings for certain foods / Wheezing
Periods of blurred vision / Pale face
Repeated ear trouble / Hives
Hyperactivity / Nose runs constantly
Dizzy spells / Noticeable changes in writing throughout day
Periods of confusion / Nosebleeds
Poor concentration / Bloating or gas after eating certain foods
Epilepsy / Canker sores
Muscle cramps or spasms / Dark circles under eyes
Abnormal body odour / Stuffy nose

THE ENDOCRINE SYSTEM

Distinct, lethargic tiredness or sluggishness / Hair dry, brittle, dull, lifeless
Cold hands or feet / Flaky, dry rough skin
Mercury amalgams (fillings) / Feel stiff after sitting still for some time
Gain weight easily, fail to lose on diets / Mood swings
Constipation, less than one bowel movement a day / Usually square and wide fingernails
Low energy in the morning / High cholesterol
Low pulse rate / Low sex drive
Low body temperature, especially bed rest
Losing weight without trying / Insomnia
Heart races while at rest / Increased appetite
Feel warm/flushed at room temperature / Frequent bowel movements, diarrhea
Hands shake or tremble / Excessive sweating without exercising
Protruding tongue / Nervous behavior, hyperactivity
Heart palpitations
Headaches affecting one side of head / Excessive urination
Female: Loss of menstrual function / Pain in little finger of left hand
Moody / Swelling in ankles, fingers and/or feet
Overweight from waist up / Cold hands or feet
Overweight from waist down / Pain in left side of upper neck
Stress or emotional upset cause exhaustion / Occasional cold sweats
Dizzy/light-headed upon standing quickly from a lying or crouched position / Tightness or lump in throat, especially when emotionally disturbed
Sweat excessively / High or low blood pressure
Neck and/or shoulder tension/pain / Rapid pulse
Frequent headaches / Short temper
Bow lines (depressed furrows) on fingernails / Puffy face

Forgetfulness, “brain fog” / Low resistance to infections, catch cold/flu easily
Energy crash mid-afternoon (around 2-5pm) / Difficulty falling or staying asleep
Need to snack to help energy levels and cravings / Increased muscle soreness with similar physical activity level
Abdominal weight gain / Female: Worsened PMS symptoms during menstrual cycle
Low sex drive or lack of interest / Frequently wake up around 2-4pm, can’t fall back asleep
Anxiety, irritability, depression (mood swings) / Low stamina, energy and difficulty maintaining muscle mass
Decreased ability to deal with stress and deadlines / Low tolerance towards alcohol or caffeine
Strong carbohydrate or salt cravings / Cold hands or feet/other extremities
Hair loss / Dry skin
Significant improvements in stress levels during vacation or time away from work?

THE STRUCTURAL-MUSCULAR/SKELETAL SYSTEM

Pain, swelling, stiffness in joints / Rounding of shoulders, stooping
Joint inflammation (rheumatoid arthritis) / Female: Menopause
Pain, stiffness, inflammation of spine / Pain in forearm or biceps
Facial pain / Cramps in calf muscle during sleep or exercise
Joints making popping sounds / Painful cramping in feet or toes
Gout / Teeth prone to decay; frequent toothaches
Ankylosing spondylitis / Malformation of bones
Bones fracture easily / Insomnia
Gradual loss of height / Muscles weak, weak grip, light objects feel heavy
Tooth loss; teeth “falling out” / Heart palpitations
Lack of exercise / Diet high in animal foods (meat, dairy, eggs)
Muscle pain / Sprains; muscle strains
Muscle weakness / Muscle(s) spasm
Muscle wasting in some part of the body / Tremors
Numbness or loss of sensation / Loss of peripheral vision
Mood swings and/or depression / Slurred speech
Blurred or double vision / Objects fall from hand, reach in wrong place
Tingling and/or numbness, especially in extremities / Hands tremble
Muscular stiffness / Impaired speech
Male: Impotence / Difficulty breathing

COMMENTS:______

Nutrient Deficiency Test

PLEASE COMPLETE THE FOLLOWING TEST USING THE SAME RATING SYSTEM:1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.