NUTRITION

Adult Questionnaire

Client confidentiality will be maintained at all times. The information provided on this questionnaire may only be disclosed with the express written consent of the individual named herein or, if under the age of 18, his or her legal guardian.

Please allow 30-45 minutes to complete most of this questionnaire. The 3-day diet diary will require you to record your food and beverage intake over a 3-day period. Please answer the questions below as thoroughly as possible so that we may make the best possible clinical assessment. This helps us develop a realistic and workable plan for supporting you in reaching your health goals. Your answers to personal questions such as relationship status, religion, etc. are important as they provide helpful context for establishing a productive partnership with you. That said; please answer only the questions you are comfortable answering.

    Basic Information






    Contact Information















    Occupation & Interests



    Demographics







    Relationship Information




    Personal Information





    Primary Reasons for Visiting a Nutritionist




    Medical Information










    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

    Action

    Women Pregnancies (Please include losses/terminations)

    Year

    Vaginal/C Section

    Sex

    Complications/Other Things You Want to Mention

    Action

    Physical Activity

    PHYSICAL ACTIVITY

    Frequency

    Comments

    Monthly

    Weekly

    Daily

    Multiple times a day

    Active lifestyle

    Cardio type exercise

    Strength building exercise

    Stretching

    How would you categorize your activity level?

    Lifestyle

    Sexual Activity

    Socializing w/Friends

    Relaxation/Self Pampering

    Tobacco

    Recreational Drugs

    Teeth Flossing

    Stress

    Do you feel that your current state of health is:



    Moods You Experience Frequently

    Significant Life Events

    Date

    Event

    Action

    Metabolic Screening Questionnaire

    Rate each symptom based on your health for the past 30 days
    (0 = Never or almost never have the symptom., 1 = Occasionally have it; effect is not severe., 2 = Occasionally have it; effect is severe., 3 = Frequently have it; effect is not severe., 4 = Frequently have it; effect is severe.).


    Point Scale:

    • 0 = Never or almost never have the symptom

    • 1 = Occasionally have it; effect is not severe

    • 2 = Occasionally have it; effect is severe

    • 3 = Frequently have it; effect is not severe

    • 4 = Frequently have it; effect is severe


    The Medical Symptom Questionnaire was developed by Jeffrey Bland, PhD.

    Head

    Headaches

    Faintness

    Dizziness

    Insomnia

    Total:

    Ears

    Itchy ears

    Earaches, ear infections

    Drainage from ear

    Ringing in ears, hearing loss

    Total:

    Heart

    Irregular or skipped heartbeat

    Rapid or pounding heartbeat

    Chest Pain

    Total:

    Emotions

    Mood swings

    Anxiety, fear, or nervousness

    Anger, irritability or aggressiveness

    Total:

    Joints/Muscles

    Pain or aches in joints

    Arthritis

    Stiffness or limitation in movement

    Pain or aches in muscles

    Feeling of weakness or tiredness

    Total:

    Energy/Activity

    Fatigue, sluggishness

    Apathy, lethargy

    Hyperactivity

    Restlessness

    Total:

    Lungs

    Chest congestion

    Asthma, bronchitis

    Total:

    Eyes

    Watery or itchy eyes

    Swollen, reddened, or sticky eyelids

    Bags or dark circles under eyes

    Blurred or tunnel vision

    Slurred speech

    Total:

    Mind

    Poor memory

    Confusion, poor comprehension

    Poor concentration

    Difficulty in making decisions

    Stuttering or stammering

    Learning disabilities

    Total:

    Mouth/Throat

    Chronic coughing

    Gagging, frequent need to clear throat

    Sore throat, hoarseness, loss of voice

    Swollen or discolored tongue, gums, lips

    Canker sores

    Total:

    Skin

    Acne

    Hives, rashes, or dry skin

    Hair Loss

    Flushing or hot flashes

    Excessive sweating

    Total:

    Nose

    Stuffy nose

    Sinus problems

    Hay fever

    Sneezing attacks

    Total:

    Weight

    Binge eating/drinking

    Craving certain foods

    Excessive weight

    Compulsive eating

    Water retention

    Underweight

    Total:

    Other

    Frequent illness

    Frequent or urgent urination

    Genital itch or discharge

    Grand Total:

    Symptom Questionnaire

    Section 1

    Indigestion, burping, bloating or sleepy immediately after meals

    Tendency to allergies, eczema, asthma

    Nausea in evenings

    Proteins hard to digest, complex meals hard to digest (combination of proteins and carbs)

    Loss of taste for meat

    Sense of excess fullness after meals

    Feel like skipping breakfast, overall low appetite

    Undigested food in stool

    Anemia, unresponsive to iron

    Section 2

    Heartburn or acid reflux symptoms

    Nausea in mornings

    Strong appetite, demanding hunger, excess salivation

    Aggravated by spice or sour, sour burps, sour smell

    Section 3

    Pain between shoulder blades

    Stomach upset by fatty or fried foods

    Loose stools with fatty foods, irregular stools, fat in stools (shiny, floating), smelly stools

    Nausea

    Light, clay colored or greenish/yellow stools

    Dry skin, itchy feet or skin peels on feet

    Gallbladder attacks

    Gallbladder removed

    Bitter taste in mouth, especially after meals

    Easily intoxicated or hung if you were to drink wine

    Pain under right side of rib cage

    Hemorrhoids or varicose veins

    Sensitive to chemicals (perfume, cleaning agents, etc.), diesel fumes or tobacco smoke

    Section 4

    Food allergies or sensitivities (wheat or grain, or dairy or other)

    Frequent intake of allergenic food(s), strong attachment to allergenic foods

    Craving, addiction or binging of allergenic foods(s)

    Abdominal bloating 1-2 hours after eating

    Pulse speeds up after eating

    Crohn’s disease, frequent sinus infection, migraines, asthma

    Airborne allergies

    Experience hives

    Section 5

    Catch colds at the beginning of winter

    Frequent colds, flu or other infections (sinus, ear, bladder, skin, etc.)

    Experienced a mucous producing cough

    Never get sick

    History of Epstein Bar, Mono, Herpes, Shingles, Chronic Fatigue Syndrome, Hepatitis, or other chronic viral conditions

    Have food allergies or sensitivities

    Section 6

    Coating on your tongue

    Anus itches

    Fungus or yeast infections

    Yeast symptoms increase with sugar, starch or alcohol consumption

    Less than one bowel movement a day

    Excessive foul smelling lower bowel gas

    Irritable bowel or mucous colitis

    Bad breath or strong body odor

    Cramping in lower abdominal region

    Stools are difficult to pass

    History of parasites

    Stools have corners or edges, are flat and ribbon shaped

    Section 7

    Eat less than five servings of (one-half cup cooked, 1 cup raw) of colored vegetables or fruits a day

    Crave sweets, breads, rolls, cookies, pasta, pizza or chips

    Crave coffee or sugar in the afternoon

    Sleepy in the afternoon

    Fatigue is relieved by eating

    Binging or uncontrolled eating

    Excessive appetite

    When you eat snacks/sweets, do you eat them, get a temporary boost of energy and mood, and later crash?

    Headache, irritability or shakiness if meals are skipped or delayed

    Heart palpitations after eating sweets

    Have frequent thirst

    Have frequent urination

    Once you start eating sweets or carbohydrates, do you feel you can’t stop

    Tend to gain weight in the belly

    Have pre-diabetes, diabetes, PCOS, hypoglycemia or alcoholism or a family history of any one of these

    Have elevated triglycerides or cholesterol

    Have high blood pressure

    Section 8

    Have high or low blood pressure

    Have a low libido

    Have trouble falling asleep

    Get less than 8 hours a sleep a night

    Go to bed frequently after midnight

    Get less than 1 hour a day of sunlight

    Work the night shift

    Are you an emotional eater

    Feel anxious or have panic attacks

    Are you a shallow breather

    Experience heart palpitations

    Cravings for salt or sweets

    Experience chronic or prolonged fatigue

    Does fatigue prevent you from doing things you would like to do. Interfere with your work, family or social life

    Do you feel you can’t get started in the morning without coffee or caffeinated drinks

    Section 9

    Are you cold when everyone else is warm

    Have coarse or brittle hair

    Experience constipation

    Have thinning hair or hair loss

    Experienced a loss of sex drive

    Lost the outside of your eyebrow

    Experience depression

    Have trouble losing weight

    Have a low blood pressure or heart rate

    Have elevated cholesterol

    Have a hoarse voice

    Have dry, scaly skin

    Have cold hands and feet

    Experience fatigue

    Experience fluid retention

    Section 10

    Aware of irregular or heavy breathing

    Experienced discomfort at high altitudes

    Sigh frequently or “air hunger”

    Experience swelling of the ankles, especially at end of day

    Blush or face turns red for no reason

    Experience a dull pain or tightness in chest and/or radiate into left arm, worse on exertion

    Have muscle cramps on exertion

    Section 11

    Rarely break out into a sweat

    Use aluminum cooking equipment

    Have mercury amalgams

    Heat food in plastic containers in microwave

    Have your clothes dry-cleaned

    Eat “fast-food” > 2 times a week

    Drink tap, well or bottled water

    Have strong body odor

    Have acne on face or buttocks

    Drink < 4 cups water a day (approximately 30 oz)

    Live in a large urban or industrial area

    Use lawn or garden chemicals

    Have less < 1 bowel movement per day

    React to small amounts of alcohol

    Sit on your computer 3+ hours a day

    Exercise < 3 times a week

    Use tobacco products

    Eat large fish (sword fish, tuna, shark, tilefish) more than once a week

    Urinate small amounts of dark urine only a few times a day

    Frequently exposed to solvents and chemicals at work or at home

    Feel any of the following: wired, increased aches in muscles and joints, anxiety, palpitations, sweating, dizziness when using caffeine

    Have a negative reaction when you consume foods containing MSG, sulfites or other preservatives

    Nutrition Frequency

    Food/Drink

    Select Frequency

    Comments

    Caffeine

    Soda/Soft Drinks

    Alcohol

    Herb tea

    Red Meat

    White Meat

    Eggs

    -

    Fish/Shellfish

    -

    Nuts & Seeds

    -

    Fruits

    Vegetables

    Lentils & Beans

    Oils / fats (e.g., olive, butter)

    Dairy Products

    Soy Products

    Whole grains

    Grain-based products

    BreadPastaCrackers

    ”Junk / Fast Food”

    Fried Foods

    Artificial Sweeteners

    Chewing Gum


    BreakfastLunchDinner


    ozBottledFilteredTap

    Using a scale of 1-10, 10 being most committed/ready/confident





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