FUEL4U Adult Questionnaire

Client confidentiality will be maintained at all times. Please allow 30-45 minutes to complete this questionnaire.

Basic Information

Primary Physician's Name

Physician Office Number

Physician Address

Physician Fax Number

Today's Date

Contact Information

Name

Address

Work Phone

Home Phone

Mobile Phone

Preferred Contact Method

Best Time(s) of Day to Reach You

Emergency Contact (Name, Relationship, Phone)

Occupation & Interests

Occupation

What are your interests/passions?

Demographics

Date of Birth

Gender

Ethnicity

Height

Highest Adult Weight

Lowest Adult Weight

Relationship Information

Status

Partner's Name

Partner's Gender

Personal Information

Religion

Education

With whom (persons or animals) do you share your home?

What types of health practitioners are you currently working with?

Primary Reasons for Visiting a Nutritionist

Reason 1

Reason 2

Reason 3

Medical Information

Health concerns experienced as a child

Health concerns experienced as an adult

Diagnosed medical conditions

Recovery program (if applicable)

Allergies (foods, medications, chemicals, environmental)

Typical reaction and severity (1-10)

Surgeries/operations (what and when)

Hospitalizations (when and why)

Major chemical exposure (when and what)

Lived or traveled outside U.S./Canada (where and when)

Recent medical test/lab work results

Family History

Relationship	Alive/Deceased	Present Health or Cause of Death
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Father
Mother
Brothers
Sisters
Children/Ages

Medications & Supplements

Name	Dosage	Frequency	Length of Time	Reason for Taking

Lifestyle

	Monthly	Weekly	Daily	Multiple times a day
Sexual Activity
Socializing w/Friends
Relaxation/Self Pampering
Tobacco
Recreational Drugs
Teeth Flossing

Stress

On a scale of 1-10, how stressful is your:

Work

Social/Family Situation

Current Health Status

Life in General

Do you feel that your current state of health is:

Largely in your control

Largely out of your control

What can you do to make a difference in your current health status?

What 1-2 key steps have you already taken?

Significant Life Events

Date	Event

Metabolic Screening Questionnaire

Rate each symptom based on your health for the past 30 days (0 = Never, 1 = Rarely, 2 = Occasionally, 3 = Frequently).

Digestive Tract

Nausea or vomiting

Diarrhea

Symptom Questionnaire

Section 1

Indigestion, burping, bloating or sleepy immediately after meals

Heartburn or acid reflux symptoms

Nutrition Frequency

Food/Drink	Monthly	Weekly	Daily	Multiple times a day	Comments
Caffeine
Soda/Soft Drinks

How many times each week do you eat each meal at home (vs. out)?

Approximately how many ounces of water do you drink per day?