Nutrition & Whole Health Solutions
50 Loomis St
Bedford, MA 01730 Ste 101
Phone: 339.970.2310
Web: www.nutritionwholehealthsolutions.com
NUTRITIONAL ASSESSMENT
Name:______Age:______Date:______Date of Birth:______
Height:______Weight:______How long have you been at your current weight?______
How did you hear about Nutrition & Whole Health Solutions?______
Is this your first nutritional consultation? If no please briefly describe your past experiences:______
Main reason (s) for seeking nutritional counseling and or Nutrition Response Testing?____
______
CONTACT INFORMATION
Home Phone:______Cell phone and or work phone:______
Home Address______Email:______
MEDICAL HISTORY
Medical History (in chronological order if possible: surgeries, accidents, medical diagnosis’s, illnesses, when and if your weight has become an issue, abnormal lab work, experiences with anxiety, depression, GI Distress, bloating, migraines/headaches and any current symptoms you would like to handle):
______
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Women’s Health History (age of first menses, what forms of birth control you have used if any, symptoms associated with PMS: cramps, mood swings, headaches, etc.)
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Family Medical History (diabetes, heart disease, cancer etc.):______
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Are you pregnant or trying to become pregnant?:______
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Known Food Allergies/Sensitivites:______
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Are you on a specific diet (gluten-free, vegetarian, dairy-free, etc.)? If so, what kind of diet do you follow?______
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Please list any medications and or supplements you are currently taking as well as past medications/supplements:______
Do you smoke? If so for how long?:______Do you consume alcohol? If so please describe what kind of alcohol and how many times per week:______
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QUESTIONNAIRE
Describe what a typical weekday is like for you. What you do for work, the type of work you do, your daily responsibilities either as a parent, employee, volunteer, spouse, etc.______
______On a scale of 1 to 10, 10 being the best, what would you rate your daily average levels on the following: Energy:____ Mood:____ Libido:____ Sleep:____ Skin Health: ____
Please check off how stressed out you feel on average? I Never Feel Stressed ____
I Feel Little Stressed ____ I Feel A Lot of Stress ____ I Always Feel Stressed Out!!!____
What could you realistically do to decrease the amount of stress in your life?______
______
How much water do you drink in 1 day?______
How often do you exercise? If so, please describe your workout schedule?______
______
Do you crave sweets? If so what kinds? Do you ever crave salty foods? If so which foods?______
In general, how many hours do you sleep a night?______
Do you sleep through the night?______Repeated Interruptions?______
Do you count calories and or try to eat a certain amount of calories a day? If so, what is the amount of calories you aim for?______
What is your blood type?______
Do you have any scars (childbirth, surgery, burns, injury(s))?______
Please check off (x) if you have had in the last 6 months:
Depression ______Fatigue ______Temper/Mood Swings ______
THREE DAY FOOD RECALL:
A three day food-recall consists of writing down everything you eat and drink for three days. Please include 2 week days and 1 weekend day and the times of each of your meals/snacks. This will give me a rough estimate of what you consume on a daily basis. Be as truthful as possible, I am not here to judge what you eat, I am here to help improve your diet and overall health. Please mention at the end of each day if you exercised and if so what type of physical activity you took part in.
Weekday #1:
Breakfast:Lunch:
Dinner:
Snacks & Times of Day:
Daily Activity:
Weekday #2:
Breakfast:Lunch:
Dinner:
Snacks & Times of Day:
Daily Activity:
Weekend Day:
Breakfast:Lunch:
Dinner:
Snacks & Times of Day:
Daily Activity:
NUTRITIONAL GOALS
What are your primary nutritional/health goals?______
______
Please describe, if any, barriers that might prevent you from achieving these goals? ______
______
What would be some solutions to these barriers that you could realistically incorporate into your life?______
Do you see yourself REALISTICALLY taking the necessary steps (meal preparation, time management, dietary changes, possibly eliminating certain foods from your diet, etc.) in the near future in order to improve your overall health and well being? ______
______
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Cancellation Policy:
Cancellations/changes must be made 24 hours in advanced. Late cancellations/no shows will be charged the full price of the appointment. We appreciate your understanding and compliance and look forward to
working with you.
Signature:______Date: ______