Nutrition Intake Form

Date

Legal Name

How do you like to be addressed?

Date of Birth

Home Address

Home/Cell Phone

Work Phone

Email Address

Referred by

What is your gender?

Female Transgender: FTM Male Transgender: MTF Other

If other, please specify.

What is your ethnicity?

Hispanic or Latino/a

Mexican

Latin America

Non-Hispanic or Latino/a

What is your race?

American Indian or Alaska Native

Asian

Black or African

Native Hawaiian or Other Pacific Islander

White

Other

If other, please specify.

CONCERNS

What do you hope to achieve in your visit with me? (List all concerns you would like to address)

When was the last time you felt well?

If known, what trigger changed your health?

How many days of work or school have you missed in the past 12 months due to your health?

< 5

> 15

< 15

Readiness Assessment

5= Very ready, I can do this!

4= Ready, but I have some concerns about implementing it

3= Somewhat ready

2= I don’t think I want to do this now but maybe in the future

1= Not ready

Significantly change my diet

Record my daily food intake

Participate in regular physical activity

Participate in forms of stress management

Improve my sleep

Take supplements daily

How motivated are you to resolve your health concerns?

Extremely motivated doing whatever it takes!

Very motivated but I might have some barriers.

Somewhat motivated but this is my starting point.

What barriers might interfere with your reaching your health goals or implementing a nutrition protocol?

Finances

Significant other/family/friends

Time/ Time Management

Travel Schedule

Social Environment

Cooking Skills

Other

If other, please specify.

FAMILY HISTORY

If other, please specify.

Indicate who below (grandmother, father, sister, etc.)

Grandparents

Ages

Living or Deceased

Parents

Ages

Living or Deceased

Siblings

Ages

Living or Deceased

PERSONAL MEDICAL HISTORY

Who is your Primary Care Physician? Please include address, phone number, and fax number.

Birth History

Did your mother have any pregnancy or delivery complications with you?

Were you born

Term Premature

Were you

Breastfed Bottle Fed

Did you eat a lot of sugar as a child?

Yes No

Medical Diagnosis

Indicate any medical diagnosis, past or current

GASTROINTESTINAL

Irritable bowel disease

Gastritis

GERD (reflux)

Hepatitis

Inflammatory bowel disease

(Crohn’s or Ulcerative colitis)

Peptic ulcer disease

Gallbladder removal

Other

CARDIOVASCULAR

Heart Attack

Hypertension

Arrhythmia

Anemia

Stroke

Hypotension

Elevated cholesterol

Mitral Valve Prolapse

Other

If other, please specify.

CANCER

Lung

Colon

Prostate

Breast

Ovarian

Skin

Other

GENITAL /URINARY

Kidney Stones

Interstitial Cystitis

Yeast infection

Gout

Urinary Tract Infection

Erectile dysfunction

Other

MUSCULOSKELETAL

Osteoarthritis

Fibromyalgia

Osteoporosis

Chronic Pain

Other

RESPIRATORY

Asthma

Bronchitis

Tuberculosis

COPD

Chronic Sinusitis

Emphysema

Sleep Apnea

Other

SKIN

Eczema

Acne

Psoriasis

Hives

Other

List any other diagnosis or illnesses not listed above

List all hospitalizations, including reason and date occurred?

Please list any major accidents (motor vehicle, sports, etc.) with dates and site of injury

Date of last physical exam?

Date of last blood work?

Medical Imaging & Testing

X-ray: Provide date, area of body, and reason?

Ultrasound: Provide date, area of body, and reason?

MRI/CAT Scan: Provide date, area of body, and reason?

GI Series: Provide date, area of body, and reason?

(colonoscopy, endoscopy)

Other tests: Provide date, area of body, and reason? (Cardiac Stress test, EKG, others)

Surgeries

Select box and provide the date of surgery

Appendectomy

Hysterectomy

Gallbladder

Hernia

Tonsillectomy

Dental

Joint Replacement

Heart

Angioplasty/Stent

Pacemaker

Other

None

Blood Type?

Rh+

Unknown

Provide any known genetic information (i.e. MTHFR, BRCA, etc.)

GI History

Any foreign travel?

Yes No

Any wilderness camping?

Yes No

Did any of your GI symptoms worsen or seem unresolved after foreign travel or camping?

Yes No

Have you ever had severe?

Gastroenteritis Diarrhea

Do you feel like you digest food well?

Yes No

Do you bloat after meals?

Yes No

If yes, how soon following a meal?

If yes, does a bowel movement or passing gas relieve it?

Yes No

If yes, where do you feel bloated?

Upper abdominal Lower abdominal Both

How many bowel movements do you have per day?

Every other day

Other

General form?

Well

Mushy

Soft

Watery

Pellets

Other

If other, please specify.

General Color

Do your stools:

Float Sink Both

Have you had exposure to or history of?

Parasites

C-Diff

Candida

Other bacteria/virus

Weight History

Height

Current Weight

Usual weight range +/- 5 lbs

Desired weight range +/- 5 lbs

Highest adult weight

Lowest adult weight

Have you recently had undesired or unexplained weight loss?

Yes No

Have you ever had your resting metabolic rate checked?

Yes No

How often do you weight yourself?

Daily Weekly Monthly Never/Rarely

Allergies

Please indicate any allergies. (Do not include intolerances)

No known or suspected allergies

Medication

Foods

Environmental

Please indicate allergy and describe reaction

Medications & Supplements

List all known allergies to medications or supplements

Current Medications (include prescribed and over the counter)

Add Current Medication

Previous Medications (include prescribed and over the counter taken in the past 12 months)

Add Previous Medication

Nutritional Supplements (vitamins, minerals, herbs, homeopathy)

Add Nutritional Supplement

Have your medications or supplements ever caused you any side effect or problems?

Yes No

Have you had prolonged use of NSAIDs (Advil, Aleve, Motrin) or aspirin?

Yes No

Have you had prolonged or regular use of Tylenol?

Yes No

Have you had prolonged use or regular use of acid blocking drugs (Tagamet, Prilosec, Nexium, etc.)?

Yes No

How many times per year do you take antibiotics?

Have you taken antibiotics long-term at any time in your life?

Yes No

Were you given antibiotics often as a child?

Yes No

Have you used steroids (prednisone, nasal allergy inhalers, etc.) in the past?

Yes No

Have you taken oral contraceptives in the past?

Yes No

SOCIAL HISTORY

What is your current job?

Do you enjoy your job?

Yes No

How many hours do you work each week?

What are your hobbies?

Relationship

Relationship status?

Single

Married

Domestic partner

In a relationship

Separated

Divorced

Widowed

Other

Are you satisfied with your significant relationships?

Yes No

Do you live alone?

Yes No

Do you have a support system?

Strong Moderate Limited

LIFESTYLE HISTORY

Stress

Do you feel you have an excessive amount of stress in your life that is impacting your health or well-being?

Yes No

Major stressors in the last year? Rate on a scale of 1-10 (10 being the most stressful)

Money

Job

Marriage/relationship

Social life

Children

Loss

Health Concerns

Other

Are you currently in therapy?

Yes No

Do you practice any relaxation techniques?

Yes No

If yes, check all that apply:

Yoga

Meditation

Guided Imagery

Breathing

Tai Chi

Prayer

Other

If other, please specify.

Do you find your life?

Satisfactory

Unsatisfactory

Boring

Too demanding

Sleep

Time to bed

Time you wake

Do you sleep and wake at the same time on the weekend and weekdays?

Yes No

Do you wake feeling refreshed?

Always Usually Rarely Never

Are you a

Morning Person

Night owl

Neither

Do you have difficulty sleeping?

Yes No

Any trouble falling asleep?

Yes No

Any trouble staying asleep?

Yes No

Do you snore?

Yes No

Do you grind your teeth?

Yes No

Do you have nightmares?

Yes No

Do you sleepwalk?

Yes No

Do you wake due to pain?

Yes No

Do you dream?

Yes No

How many times do you wake during the night?

none once twice more

What is the reason for waking?

bathroom use

pain

racing mind

child/children

pet

significant other

Other

Do you need a sleep-aid?

Yes No

If yes, please indicate.

Energy

Please indicate your average level of energy throughout the day using the scale 1-10 (1 is the lowest and 10 is the highest)

Overall

Upon waking

Noon

Mid Afternoon

Early Evening (5-6pm)

Are you easily fatigued?

Yes No

Do you nap during the day?

Yes No

If yes, does it improve your energy?

Yes No

If you could nap during the day, would you?

Yes No

Alcohol, Tobacco, and Recreational Drug Use

Do you drink alcohol?

Daily

Weekly

Monthly

Less than monthly

Special Occasions

What type of alcohol do you prefer?

Liquor

Wine

Beer

Other

How much do you drink per sitting? Indicate amount consumed per occasion.

Do you smoke or chew tobacco?

Yes No In the past

If yes, how many cigarettes or packs per day?

If past, when did you quit smoking/chew, number of years smoking/chew, and packs per day?

Do you use recreational drugs?

Yes No In the past

If yes, how often?

Daily Weekly Monthly Other

Have you ever been told you have an addiction or been treated for an addiction?

Yes No

Does the use of alcohol or drugs impair your activities of daily living?

Yes No

Physical Activity

Are you currently engaging in regular physical activity?

Yes No

If yes, indicate details below.

If no, list any activities you enjoy doing or have enjoyed in the past.

Aerobic/Cardio Type

Times per week

Duration

Strength Training: Times per week

Duration

Stretching: Times per week

Duration

Formal Sports : Times per week

(basketball, tennis, etc.)

Duration

Other Activity

Duration

Do you continue to exercise when under stress or busy?

Yes No

Do you usually sweat with exercise?

Yes No

Do you feel unusually fatigued after exercise?

Yes No

List any concerns that limit your ability for physical activity.

Environmental Exposures

Which of the following significantly affect you?

Cigarette Smoke

Exhaust Fumes

Perfumes/Colognes

Cleaning Products

Other

Do you have any pet or farm animals?

Yes No

Nutrition

Have you ever had a nutrition consultation?

Yes No

Have you made changes in your eating habits because of health concerns?

Yes No

Do you currently follow a special diet or nutritional program?

Yes No

Do you have any known food allergies, sensitivities or intolerances?

Yes No

If yes, provide the food and the type of reaction you experience.

Do you frequently skip or miss meals?

Yes No

Do you read food labels?

Yes No

Do you grocery shop?

Yes No

Do you cook?

Yes No

How many meals do you eat out each week?

0-1 2-3 4-5 >5

If you could only eat a few foods per week, what would they be?

What are the 3 healthiest foods you eat each week on a regular basis?

What are the 3 unhealthiest foods you eat each week?

How many meals do you eat a day?

How many 8oz cups of water do you drink daily?

Do you drink energy drinks?

Daily Weekly Monthly No

Please indicate what kind of energy drink and how much.

Do you drink soda, juice or sports drinks?

Daily Weekly Monthly No

Please indicate what kind of soda, juice or sports and how much.

How many 8oz cups of coffee do you drink daily?

Do you use sweeteners?

Sugar

Equal

Xylitol

Stevia

Splenda

Maple Syrup

Sweet-n-Low

Honey

Other

Do you eat meals (check all that apply)

In front of TV

Alone

In the car

With others

At your desk

Other

If other, please specify.

What is your general mood when eating?

Rushed

Distracted

Mindful

Other

If other, please specify.

The most important thing I should change about my diet to improve my health is.

REVIEW OF SYSTEMS

Do you have, or have you had within the past year, any of the following?

General

cold hands or feet

cold intolerance

heat intolerance

chills

fatigue

night sweats

Date of last eye exam

Cardiovascular

murmurs

palpitations

irregular heartbeat

swollen hands/feet

blue hands/feet

chest pain

varicose veins

Respiratory

cough-dry

hay fever

wheezing

winter congestion

cough-productive

shortness of breath

pain with breathing

Musculoskeletal

muscle weakness

muscle aches/pain

joint injury

TMJ

muscle cramps/spasms

joint stiffness

joint pain

joint deformity

Mood/Emotional

anxiety

panic attack

irritability

depression

suicidal thoughts

anger

If other, please specify.

Dental

tooth pain

chewing difficulties

floss daily

bleeding gums

trouble swallowing

mercury fillings

root canals

FEMALE SECTION

(Only females complete this section)

Menstrual Cycle

Age of first menses?

First day of last menses?

Length of menses?

Characters of menses such as color and clots?

Number of pads/tampons used on your heaviest day?

Number of pads/tampons used on your lightest day?

Do you have clots with the menstrual cycle?

Yes No

Do you have pain during the menstrual cycle?

Yes No

Have you ever skipped a period?

Yes No

If yes, how long.

Type of contraception used currently or in the past.

Have you been diagnosed with any of the following?

PCOS

infertility

fibrocystic breasts

PMDD

uterine fibroids

endometriosis

pelvic inflammatory disease

Menopause

Surgically induced menopause

Total hysterectomy

Partial hysterectomy

Age at menopause

Age your mother entered menopause

If other, please specify.

Date of last DEXA scan (bone scan)

Indicate if you never had one

Breast Health

Do you have a history of breast cancer?

Yes No

Do you have a family history of breast cancer?

Yes No

Do you have any of the following?

breast pain

breast discharge

breast masses

Date of last mammogram and results

Gynecology and PAP History

Date of last PAP smear and results

Have you ever had an irregular PAP smear?

Yes No

If yes, list date and treatment received.

Check all the pelvic symptoms you currently experience

vaginal itching

vaginal odor

pelvic pain

low libido

abnormal discharge

rashes or skin changes

pain with intercourse

bleeding after intercourse

Pregnancy History

Number of pregnancies

Number of miscarriages

Number of abortions

Any complications with pregnancy?

Yes No

Any difficulty with conceiving?

Yes No

Post-Partum depression?

Yes No

Number of vaginal births

Number of C-Sections

MALE SECTION

(Only males complete this section)

Date of your last PSA?

Date of your last prostate exam (digital rectal exam)?

Additional Information

Is there anything else you would like your nutritionist to know about you?

MSQ - MEDICAL SYMPTOM / TOXICITY QUESTIONNAIRE

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

HEAD

Headaches

Faintness

Dizziness

Insomnia

TOTAL

HEART

Irregular or skipped heartbeat

Rapid or pounding heartbeat

Chest pain

TOTAL

JOINT/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

Stuttering or stammering

Slurred speech

Learning disabilities

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

KEY TO QUESTIONNAIRE

Add individual scores for each group. Add each group scores to get a grand total.

Optimal is less than 10. | Mild Toxicity: 10-5- | Moderate Toxicity: 50-100 | Severe Toxicity: over 100

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