Nutritional Questionnaire for Adults
Myabilitytodraweffectiveconclusionsaboutyourpresentstateofhealthandhowtoimproveitdepends,toasignificantextent,onyourabilitytorespondthoughtfullyandaccurately to thesequestions. Healthissuesareusually influencedbyseveralfactors. Accuratelyassessingallthefactorsandcomprehensivelymanagingthemisthebestwaytodealwithyourhealthchallenges.Toenhanceyourscheduledconsulttime,pleasehavethisbacktomeatleast1 daypriortoyourappointment,ifpossible.Please email it to
Name: Today’sdate:
Address: City: State: Zip:
E-mailAddress: FaxNumber:()-
HomePhone:()- Work:()- Cell:()-
Birthdate:Age: PlaceofBirth:
Occupation: Referred By: Blood Type:
Height: Weight: Sex: DesiredWeight: LastAgeatDesiredWeight:
HighestAdultWeight: WhatAge?: LowestAdultWeight: WhatAge?:
Haveyoueverdieted?:Yes No IfYes,howmanytimesinyouradultlife?
Whichdiet(s)worked:
1.Pleasecheckappropriatebox:
AfricanAmerican / Hispanic / Mediterranean / AsianNativeAmerican / Caucasian / NorthernEuropean / Other
2.Pleaserankcurrent/ongoingproblemsbypriorityandfillintheotherboxesascompletelyaspossible:
DESCRIBEPROBLEM / MILD/MODERATE/ SEVERE / TREATMENT APPROACH / SUCCESSExample: Joint Pain / Moderate / Fish oil / Moderate
a.
b.
c.
d.
3. PAST MEDICALAND SURGICALHISTORY:
Anemia(type) / WHEN / COMMENTSAnxiety
Arthritis
Asthma
Bronchitis
Cancer
ChronicFatigueSyndrome
Crohn'sDiseaseorUlcerativeColitis
Diabetes
Depression
Epilepsy,ConvulsionsorSeizures
Gallstones
Gout
HeartAttack/Angina
HeartFailure
Hepatitis
HighBloodFats(cholesterol,triglycerides)
HighBloodPressure(hypertension)
IrritableBowel
Kidneystones
Mononucleosis
Pneumonia
Sinusitis
SleepApnea
Stroke
Thyroiddisease
Other(describe)
WOMEN’S HEALTH
Severe PMS
Fibroids
Endometriosis
Cysts
Heavy Periods
PCOS/ hormone imbalances
PROTEIN INTEGRITY
Hair – dry, brittle, falling out
Nails – weak, break easily, peel
Bruising easily
Rosacea
Joint pain/injury
Other (describe)
OPERATIONS
DentalSurgery
Gallbladder
Hysterectomy
Tonsillectomy
Other(describe)
4.Pleaseindicatesignificantfamilymedicalhistory(ex:cancer,diabetes,heartdisease,etc.)
Maternalside:
Paternalside:
5.Areyourparentsliving?NoYes
Ifno,comment:
6.Didyouhaveanyhealthissuesasachild? No Yes-Whatage?
Describe:
7.Asachild,weretherefoodsyouavoided?NoYes-(pleasespecifybelow)
Food / SymptomsEx:Milk / Ex:Gasanddiarrhea
8.Pleasemarkinthechartbelowwithinformationaboutrecentbowelmovements:
Frequency: / Color:Morethan3timesaday / Darkbrown
2-3timesaday / Mediumbrown
Onetimeperday / Verydarkorblack
4-6timesaweek / Greenish
2-3timesaweek / Bloodisvisible
Onceorfeweraweek / Variesalot
Consistency: / Yellow,lightbrown
Softandwellformed / Greasy/oily/shinyappearance
Oftenfloat
Difficulttopass
Diarrhea
Thin,longornarrow
Smallandhard
Loose,butnotwatery
Alternatingbetweenhardand loose/watery
9.Doyouexperienceintestinalgas?(checkallthatapply)
presentwithpainfoulsmelllittleodorexcessivedailyoccasionally
10.Doyouexperiencebloating? frequentlyoccasionallyrarelynever
11.Doyouexperienceanyheartburn,chestpressure,orstomachpain? No Yes
If yes, please explain:
WOMEN ONLY: (Questions 12-21)
12.Haveyoueverbeenpregnant?NoYes
Ifyes,pleaseanswerthefollowing:
a.Numberofmiscarriages:b.Numberofabortions: c.Numberofpreemies:
d.Numberoftermbirths:e.Birthweightoflargestbaby: Smallestbaby:
f.Didyoudeveloptoxemia?NoYes
g.Haveyouhadanyotherproblemswithpregnancy? No Yes
Ifyes,describe:
13. History of infertility? NoYes
14.Ageoffirstmensus:
15.DateoflastPapsmear: Normal Abnormal
16.DateoflastMammogram: Normal Abnormal
17.Doyoucurrentlyusecontraception? NoYes-(type?)
Ifyou’reonthepillpleasecommentonphysicalormentalchangesfrombeforetakingtonow:
18.DoyoucurrentlyexperiencePMS(i.e.waterretention,breasttenderness,irritability,etc.)?
NoYes-(specify)
19.HaveyoueverexperiencedPMSinthepast? No Yes–When?:
20.Areyoustillmenstruating? Yes No-(ageoflastperiod):
21.Areyouexperiencingmenopausesymptoms? No Yes
22.(MenandWomen) Doyouhaveurinaryproblems?NoYes
Ifyes,pleasespecify: NightlyurinationFrequentdaytimeurinationHesitancy
IrregularDribblingafterwards frequenturgetourinateDifficulty
FeelingofincompleteemptyingBurningsensation
23.(MenOnly): Doyouhaveprostateswelling?NoYes
DENTAL,etc.:
24.Doyouhaveamalgam(silver,blackorgrey)fillings?NoYes(howmany?):
25.Haveyoueverhadfillingsreplaced?
NoYes-(howmany?when?withwhatmaterial?)
26.Doyouhaverootcanals?NoYes(howmany?)AnyProblems?
27.Haveyouhadanycavitiesinthelast2years?NoYes(howmany?)
28.Doyourgumseverbleed?NoYes-(howoften?)
29.Doyouevergrindyourteeth?NoYes
SOCIAL:
30.Howwellhavethingsbeengoingforyoulately?
Great / Good / Couldbebetter / Notverygood / DoesNotApplyschool
job
sociallife
closefriends
sex
yourattitude
boy/girlfriend
children
parents
spouse
31.Withwhomdoyoulive?Listageofchildren,ifany.
32. Whatistheattitudeofthoseclosetoyouconcerningyourhealth?
SupportiveNotsupportiveIndifferent
33. Areyoucurrentlymarried,orhaveyoueverbeenmarried?NoYes
Ifyes,when: Ifyes,spouseʼsoccupation:
Haveyoubeenseparatedordivorced? No Yes-Ifyes,when?:
34.Whatareyourhobbiesandleisureactivities?
35. Describepreviousjobs/work:
36. Haveyouexperiencedanymajorlossesinyourlife? NoYes
Ifso,pleasecomment:
37. Haveyouoryourfamilyrecentlyexperiencedanymajorlifechanges(suchasajobchange)? No Yes
Ifyes,pleasecomment:
38. Haveyoueverhadpsychotherapyorcounseling?NoYes
Ifyes,whatkind? When?
Additionalcomments:
LIFESTYLE:
39.Howimportantisreligion(orspirituality)toyou?
NotatallimportantSomewhatimportantExtremelyimportant
40.Doyoupray or meditate?Occasionallyoftennever
41.Howmuchcontroldoyoufeelyouhaveoveryourcurrentstateofhealth?Rate1-10(none-all)
Comment:
42.Howmuchtimehaveyoulostfromworkorschoolinthepastyearduetoillness?
0-2days3-5days6-14daysmore
43.Whatisyourusualbedtime? waketime?
44.Howwelldoyousleep?(checkallthatapply)
Adequate-(sleepthroughthenight)Wakeupfeelingwellrested
TroublefallingasleepWakeupstilltired
Troublestayingasleep-(Howmanytimesdoyouwakeduringthenight?)
45.Checkofftypicalbedtimeactivities:
WatchtelevisionReadabookListentomusicBedtimesnack
MeditateBathe/showerDrinkalcoholDrinkcaffeinatedbeverage
Electronics (phone, iPad, etc.)
46.Doyoueverneedtotakeasleepaid?No Yes–Whichonesatwhatdose?
Howoften:
47.Doyouexerciseregularlynow?NoYes-(specify):Haveyouinthepast?No Yes
Onceperweek2timesperweek3timesperweek 4timesperweekormore
Amountpersession:lessthan15minutes 15-30minutes 30-45minutes45minutes
Other-(specify):
48.Whattypeofexercisesdoyoudocurrently(dogwalkingdoesnotcount)?
JoggingWalkingWeighttrainingWatersportsAerobicsYoga
Other-(specify):
49.Doyougetsunexposure?NoYes-(specify):DailyWeeklyHowmuch?
50.Doyouwearsunblock?NoYes-(percentageoftime)
ALLERGY &TOXIC POTENTIAL:
51.Doyouhaveanypets?NoYes-List:
Ifyes,wheredotheylive? IndoorsOutdoorsBoth
52.Doodorssuchasperfume,cleaningsolutions,smoke,etc.affectyou?No Yes
Ifyes,explain:
53.Haveyou,toyourknowledge,beenexposedtotoxicmetalsatyourjoborathome?
NoYes:LeadCadmiumArsenicMercuryAluminum
Explain:
54.Toyourknowledge,haveyoueverbeenexposedtoanongoingamountofanyofthefollowing?
NoSolventsPaintsPesticidesPetrochemicals
CoalHydrocarbonsMoldOther(specify):
55.Doyounoworhaveyourecentlylivedinanolderhome(pre1970ʼs)?: No Yes
Ifyes,howoldis/washome?Howlonghave/didyoulivethere?
56.Haveyoueverlivedorworkedinawaterdamagedbuilding?NoYes
Ifyes,when?Howlong?
57.Doyouconsumealcoholregularlynowordidyouconsumealcoholregularlyinthepast?
No / Yes-Currently:1-3drinksperweek / 4-6 / 7-10 / 10ormoreYes-Inthepast: 1-3drinksperweek / 4-6 / 7-10 / 10ormore
Ifyouhavequit,when?
58.Haveyoueverusedtobacco?No Yes-(specify:)Ifyes,numberofyears:
Amountperday: Yearquit?
59.Areyounoworwereyoueverregularlyexposedtosecondhandsmoke? No Yes When?
60.Haveyoueverusedrecreationaldrugs?NoYes-(specify:)
MEDICATIONS:
61. Whatmedicationsareyoutakingnow? Pleasealsoincludenon-prescriptiondrugsyoutakedaily/regularly.
MedicationName / Purpose / Dosage / StartDate1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
62.Doyoutakeanyotheroverthecountermedicationsonanoccasionalbasis?
Ifyes,whichone(s)?
63.Howmanytimeshaveyoutakenantibioticsasaninfantorchild?
Lessthan5timesMorethan5timesMorethan10timeSomanytimesIlostcount
Reason:
64.Asanadult,howoftendoyoutakeantibiotics?
NeverOnceayear(onaverage)1-3timesayear(onaverage)
Longer-(explain):
Why?
65.Wereyoueveronantibioticsforaprolongedperiodoftime?NoYes
Ifyes,explain:
66.Fillinthechartbelowforhowmanytimesyouhave takenoralsteroids(e.g.Cortisone,Prednisone,etc.):
Lessthan5timesGreaterthan5timesGreaterthan10times
Infancy/ChildhoodTeen
Adulthood
67.Listallvitamins,minerals,andothernutritionalsupplementsthatyouarecurrentlytaking. Indicateunit(mgorIU),andform(forexample:calciumcarbonatevs.calciumlactate).
Vitamin/HerbalSupplement(s) / Brand / HowManyandWhen? / StartDate1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
**If you’re being seen in person, pleasebring
bottleswithyoutoyour appointment**
DIETARY HABITS:
68.Areyoucurrentlyonaspecialdiet(i.e.,vegetarian,SouthBeach,etc)?NoYes
Ifyes,howlonganddescribe:
69.UsualBreakfasttime: Lunchtime:Dinnertime:
Snacktime:Snacktime: Snacktime:
70.Placeamarknexttothefood/drinkthatappliestoatypicaldayofyourcurrentdiet.
UsualBreakfast / UsualLunch / UsualDinner / UsualSnacksNone / None / None / None
Cereal / Eatincafeteria / Pasta / Nuts
WheatBran / Eatinrestaurant / Potato / Fruit
Oatmeal / Leftovers / Brownrice / Vegetables
Toast / Meatsandwich / Whiterice / Pretzels
Bagel / Fishsandwich / Beans(legumes) / PotatoChips
Breakfast bar / Lettuce(onsandwich) / Fish / CornChips
Donut / Tomato / RedMeat / Crackers
Eggs / Salad / Poultry / Cheese
Bacon/Sausage / Saladdressing / Salad / Cookies
Fruit / Soup / Saladdressing / Cake/Pastries
Yogurt / Fruit / Greenvegetables / Nutbutters
Milk / Yogurt / Carrots / Cereal
Juice / Milk / Yellowvegetables / Icecream
Tea / Juice / Milk / Trailmix
Coffee / Tea / Juice / Driedfruit
Water / Coffee / Tea / Other:(list)
Butter / Water / Coffee
Margarine / Regularsoda / Water
Sugar / Dietsoda / Regularsoda
Sweetener / Butter / Dietsoda
Leftovers / Margarine / Butter
Other: / Mayonnaise / Margarine
Sugar / Sugar
Sweetener / Sweetener
Other: / Other:
71.Doyoucurrentlyortypicallyhaveanysymptomsimmediatelyaftereating?(Forexample:belching,fatigue,bloating,sneezing,hives,etc.? No Yes Ifyes,arethesesymptomsassociatedwithanyparticularfoodthatyouareawareof? Explain:(example:Milk-gascausediarrhea)
72.Doyoufeelyouhavedelayedsymptomsaftereatingcertainfoods,suchas:fatigue,muscleaches,sinuscongestion,etc.?Delayedsymptomsmaynotbeevidentfor24hoursormoreaftereating.
NoYes
Ifyes,specify:
73.Doyoufeelmuchworsewhenyoueatanyofthefollowing:(checkallthatapply)
highfatfoodsrefinedsugar(junkfoods) highproteinfoodsfriedfoods
highcarbohydratefoods 1or2alcoholicdrinks
(breads,pastas,potatoes)Other(specify):
74.Doyoufeelmuchbetterwhenyoueatalotof:(checkallthatapply)
highfatfoodsrefinedsugar(junkfoods)highproteinfoodsfriedfoods
highcarbohydratefoods 1or2alcoholicdrinks
(breads,pastas,potatoes)Other(specify):
75.Doyoufeelworseatcertaintimesoftheyear?NoYes-(when?)
Howdoyoufeel?
76.Doyoufeelbetteratcertaintimesoftheyear? NoYes-(when?)
Howdoyoufeel?
77.Doesskippingamealaffectyouinanyway?NoYes–Explain:
78.Doyouevercraveor“binge”oncertainfoods? NoYes
Whichfoods,howoftenandcommentonpossiblestressors/triggers?
79.Doyouavoidcertainfoodsforanyreason?NoYes
Whichfoodsandwhy?
80. How many times a week do you eat out?
Rate the type of restaurants you frequently eat at in order of most to least often (1 being the kind you eat at most often, and 5 for the least often or never):
Fast foodfine dining café coffee shop or Corner bakery type place
Casual dining breakfast dinner grocery store deli health food store deli
81. Are you the primary cook for the household? . If not, who is?
82. On a scale of 1-5, rate what extend you enjoy preparing/cooking food (1 – a lot, 5 – hate it!)
83. Where do you do the bulk of your grocery shopping?
84: What percentage of your food intake is Organic?
85: Do you drink bottled water? If yes, approx. how many bottles per day?
What size?
Anythingelseyouthinkweshouldknow? This is the place where you can detail your main concerns and what you expect to get out of working with me: