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Nutritional Assessment & History Form
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Your Name
*
Your answer
Your Email
*
Your answer
How often do you check email?
Multiple Times Each Day
One Time Each Day
Every Couple of Days
Once Each Week
Every Couple of Weeks
Never, I Don't Use Email
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Your Street Address
*
Your answer
City, State, Zip
*
Your answer
Home Phone
Your answer
Work Phone
Your answer
Cell Phone
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Your Age
Your answer
Your Height
Your answer
Current Weight
Your answer
Your Weight 6 Months Ago
Your answer
Your Weight 1 Year Ago
Your answer
Why would you like your weight to be different?
Your answer
Relationship Status
Single
In a Relationship
Married
Living With Partner
Divorced
Wodowed
Prefer Not to Answer
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Number of Children
Your answer
Your Occupation
Your answer
Hours per week at your occupation
Your answer
Do You Sleep Well?
Yes
No
Sometimes
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Do You Wake Up at Night?
Yes
No
Sometimes
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At What Times Do You Wake Up at Night?
Your answer
To Urinate?
Yes
No
Sometimes
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What time do you generally get up in the morning?
Your answer
Constipation/Diarrhea?
Yes
No
Sometimes
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What is Your Blood Type?
Your answer
What is your Ancestry?
Your answer
Women: Are your Periods Regular?
Your answer
Women: How Many Days is your Flow?
Your answer
Women: Painful or Symptomatic?
Your answer
Do you take any supplements or medications? If so, which?
Your answer
Are there any healers, helpers or therapies with which you are involved?
Your answer
What role does exercise play in your life?
Your answer
Do you drink coffee, smoke cigarettes, or have any major addictions?
Your answer
What percentage of your food is home cooked?
Your answer
Where do you get the rest of your food?
Your answer
Serious illness/hospitalizations/injuries?
Your answer
What is your chief concern?
Your answer
How is the health of your mother?
Your answer
How is the health of your father?
Your answer
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