Nutritionist Intake Form

Lifestyle Assessment & Nutritional Assessment Form
Name*

First NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
How Did You Hear About Our Clinic?*
What is your purpose in coming here today?*
What are your main health concerns/complaints? Please list in priority:*
Have you experienced any major trauma in the past 5 years?*
What level of stress do you feel you are experiencing at this time? Please quantify ona scale of 1 (low) to 10 (high):*
What are the major causes or factors of your stress? Rate all that apply on a scale of1 (low) to 10 (high):*

financialcareerpersonalmarriagehealthfamilyspiritualunfulfilled expectationsOther
How does your stress manifest itself?*
Do you use any coping mechanisms? What do you do for exercise? (Indicate type, frequency, time of day and duration)*
On a scale of 1 (low) to 10 (high), how would you describe your energylevels?*
Do you experience any lulls or highs in your energy levels throughout theday? If so, at what time of day?*
How many hours on average do you sleep daily? (include naps)*
What time do you go to sleep? *

Hour Minutes

AM/PM Option
What time do you awaken? *

Hour Minutes

AM/PM Option
Do you have trouble falling asleep?*

YesNo
Do you awaken feeling rested?*

YesNo
Do you snore?*

YesNo
What is your occupation?*
Do you enjoy your work?*

YesNoSometimes
How many hours each day do you work?*
At what time do you start work?*

Hour Minutes

AM/PM Option
At what time do you end work?*

Hour Minutes

AM/PM Option
Do you work shifts or are you on a regular schedule?*
Do you smoke?*

YesNo
If yes, for how long?
If no, does anyone in your household or workplace smoke?

YesNo
Do you wish to:*

gain weightlose weightmaintain current weight
What is your goal weight and by when do you wish to reach it?
What is your main motivation for your goals?*
How many hours do you spend daily, on average:*
driving
How many hours do you spend daily, on average:*
watching television
How many hours do you spend daily, on average:*
reading
How many hours do you spend daily, on average:*
in front of a computer
What are your interests and hobbies?*
Do you vacation regularly?*

YesNo
When was your last vacation?
Do you actively participate in any spiritual discipline (church, religious group,meditation, etc.)?*

YesNo
Medical History
Are you currently taking any medication?*

YesNo
List all medications and the reason(s) for each:
Do you take birth control pills*

YesNo
Have you taken antibiotics over the past five years?*

YesNo
Please list any vitamins, minerals, herbal or homeopathic remedies you are currentlytaking and the amounts/dosages:
Do you have any allergies or sensitivities?*

YesNo
If yes, please list them:
Do you have anaphylaxis (life-threatening allergy)? If so, please describe:
Do you have any silver-mercury fillings?*

YesNo
Have you ever been diagnosed with an illness?*

YesNo
If yes, please explain:
Have you ever been hospitalized?*

YesNo
If yes, please explain:
Have you had surgery to remove:

Gall bladderTonsilsAppendix
How often do you have a bowel movement?*
Do you strain to have a bowel movement?*

YesNoOccasionally
Related to Food Issues?*

YesNo
Do you have loose bowel movements?*

YesNoOccasionally
Is there undigested food in your stools?*

YesNoOccasionally
Do you use recreational drugs?*

YesNo
If yes, how often and what type?
Have you ever been treated for drug and/or alcohol dependency?*

YesNo
Family History

Hereditary Diseases:

	Father	Mother	Sibling	Grandparent	Others
Allergies
Alcoholism
Arthritis
Asthma
Autoimmune Disease
Cancer
Diabetes
Drug Abuse
Gall Bladder Issues
Heart Disease
Hypertension
Intestinal Disease
Kidney Dysfunction
Mental Illness
Osteoporosis
Skin conditions
Ulcers

Other diseases (please list)
Have you experienced fungal infections (e.g. jock itch, athlete’s foot)?*

YesNo
If yes, please describe:
Have you experienced a decline in sexual interest?*

YesNo
If yes, please describe:
Have you had kidney or gall stones?*

YesNo
If yes, please describe:
Females
Are you or could you be pregnant?*

YesNo
Have you noticed any changes in menses, for example the frequency, duration, flow,clotting, or other changes?*

YesNo
If so, please specify:
Do you suffer from PMS symptoms? Please specify:
Are you peri-menopausal?*

YesNo
Are you menopausal?*

YesNo
Are you experiencing any menopausal symptoms?*

YesNo
If yes, please specify:
Have you had a bone density test?*

YesNo
If yes, what was the result?
Males
Have you experienced any prostate problems (e.g. frequent urination, discomfort during urination)?*

YesNo
If yes, please describe:
Dietary Habits
How many times a day do you eat:*
Main Meals:*
Times of day:*
Snacks:*
Times of day:*
Do you eat meals:*

with familyhome aloneon the runrestaurantfast foodalone
Do you feel there are restrictions to your diet due to preferences of others such asfamily, roommates, etc?

YesNo
If yes, please explain:

How many 1⁄2 cup servings of each do you typically eat in a day:

	Fresh	Dried	Canned	Cooked	Raw
Fruit
Vegetables
Whole Grains
Protein
Dairy Products
Other

Provide examples of your typical meals:*

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

	1, 2, 3
Aluminum pans
Margarine
Candy
Microwave
Fried foods
Fast foods
Luncheon meats
Artificial sweeteners (Nutra Sweet, aspartame, Splenda)
Refined foods (pastries, white bread/pasta/rice, etc.)

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

	# of Cups
Tap Water
Coffee
Tea
Soft drinks (diet)
Soft drinks (regular)
Fresh fruit juices
Fruit juices (prepared)
Milk (1%, 2%, or whole)
Refined foods (pastries, white bread/pasta/rice, etc.)
Milk (skim)
Prepared vegetable juices
Fresh vegetable juices
Red wine
White wine
Beer
Other alcoholic beverages
Bottled or spring water
Herbal tea

Are you a:*

meat eater?vegetarian?vegan?
How often do you eat meat?*

Daily3-5/weekOnce/week or less
How often do you consume dairy products?*

Daily3-5/weekOnce/week or less
What are your favourite foods?*
How often do you eat them?*
Which food(s) do you crave, and how often do you eat them?*
Do you avoid certain foods?*

YesNo
If so, why?
Do you experience any symptoms if meals are missed? Explain:
Do you experience any symptoms after meals? Explain:
Client Statement

I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date*

MonthDayYear
Date
Signature*

Clear
Thank you for your cooperation.

All information contained on this form will be kept strictly confidential.
Should be Empty:

Lifestyle Assessment & Nutritional Assessment Form

Family History

Females

Males

Dietary Habits

Client Statement