Follow-up Nutritional Consult Form

Client Follow Up Questionnaire

Client Name

Date of Birth

Today’s Date

Date of Last Visit

1) Have you noticed any change in your condition or have you developed any new symptoms since your last visit?

Yes No

If yes, please describe.

2) Have you started any new medication (prescription or over the counter) since out last visit?

Yes No

If yes, please indicate the medicine, dose, frequency of use, and reason for use.

3) Have any laboratory tests been done since our last visit?

Yes No

If yes, please indicate which test were done and provide a copy of the results.

4) In each of the areas listed below (as applicable) please indicate if it was easy or challenging to follow the recommendations provided during our last visit. Use a scale of 1-10, with one being the easiest and ten being the hardest.

Diet

Stress Management

Sleep

Dietary Supplements

Exercise/Physical Activity

3-Day Food Diary and Instructions

It is important to keep an accurate record of your usual food and beverage intake as a part of your treatment plan. Please complete this Diet Diary for 3 consecutive days including one weekend day.

Do not change your eating behavior at this time, as the purpose of this food record is to analyze your present eating habits.
Record information as soon as possible after the food has been consumed
Describe the food or beverage as accurately as possible e.g., milk - what kind? (whole, 2%, nonfat); toast (whole wheat, white, buttered); chicken (fried, baked, breaded); coffee (decaffeinated with sugar and 1/2 & 1/2).
Record the amount of each food or beverage consumed using standard measurements such as 8 ounces, 1/2 cup, 1 teaspoon, etc.
Include any added items. For example: tea with 1 teaspoon honey, potato with 2 teaspoons butter, etc.
Record all beverages, including water, coffee, tea, sports drinks, sodas/diet sodas, etc.
Include any additional comments about your eating habits on this form (ex. craving sweet, skipped meal and why, when the meal was at a restaurant, etc.)
Please note all bowel movements and their consistency (regular, loose, firm, etc.)

DAY 1

Add new row

Bowel Movements (#, form, color)

Other comments

DAY 2

Add new row

Bowel Movements (#, form, color)

Other comments

DAY 3

Add new row

Bowel Movements (#, form, color)

Other comments

MSQ – MEDICAL SYMPTOM / TOXICITY QUESTIONNAIRE

Name

Date

The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness, and helps you track your progress over time. Rate each of the following symptoms based upon your health for the past 30 days. If you are taking this for a repeat visit, record your symptoms for the past 48 hours ONLY.

Point scale:

0 = Never or almost never have these symptoms

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

DIGESTIVE TRACT

Nausea or vomiting

Diarrhea

Constipation

Bloated feeling

Belching or passing gas

Heartburn

Intestinal/Stomach pain

TOTAL

EARS

Itchy ears Total

Earaches, ear infections

Drainage from ear

Ringing in ears, hearing loss

TOTAL

EMOTIONS

Mood swings

Anxiety, fear or nervousness

Anger, irritability, or aggressiveness

Depression

TOTAL

ENERGY/ACTIVITY

Fatigue, Sluggishness

Apathy, Lethargy

Hyperactivity

Restlessness

TOTAL

EYES

Watery/itchy eyes

Swollen, reddened or sticky eyelids

Bags or dark circles under eyes

Blurred or tunnel vision

(not near or farsightedness)

TOTAL

Short text

HEAD

Headaches

Faintness

Dizziness

Insomnia

TOTAL

Short text

HEART

Irregular or skipped heartbeat

Rapid or pounding heartbeat

Chest pain

TOTAL

JOINTS/MUSCLES

Pain or aches in joints

Arthritis

Stiffness or limitation of movement

Pain or aches in muscles

Feeling of weakness or tiredness

TOTAL

LUNGS

Chest congestion

Asthma, bronchitis

Shortness of breath

Difficulty breathing

TOTAL

MIND

Poor memory

Confusion, poor comprehension

Poor concentration

Poor physical coordination

Difficulty in making decisions

Short text

Stuttering or stammering

Slurred speech

Learning disabilities

TOTAL

MOUTH/THROAT

Chronic coughing

Short Gagging, frequent need to clear throat

Sore throat, hoarseness, loss of voice

Swollen/discolored tongue, gum, lips

Canker sores

TOTAL

NOSE

Stuffy Nose

Sinus problems

Hay fever

Sneezing attacks

Excessive mucus formation

TOTAL

SKIN

Acne

Hives, rashes or dry skin

Hair loss

Flushing or hot flashes

Excessive sweating

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

TOTAL

GRAND TOTAL

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