Name
*
First Name
Last Name
Date
MM
DD
YYYY
Phone
(###)
###
####
Email
*
Birth Date
Consent
I understand that information provided on the relationship between nutrition and health is NOT meant to replace professional medical treatment for any health problem or condition. Health education and medical care are complementary and integrative when properly delivered.
Confidentiality
I understand that all information provided and discussed is confidential and will not be discussed outside of our meetings.
Height
Current Weight
Ideal Weight
Occupation
Living Situation
List Exercise/Recreation and number of times/week
Have you lived or traveled outside of the United States? If so, when and where?
Have you or your family recently experienced any major life changes? If so, please comment:
Have you experienced any major losses or traumas in you life? If so please comment:
How much time have you had to take off from work in the past year?
0-2 days
3-14 days
more than 15 days
What types of foods do you and your family eat when you were growing up? What comfort foods do you recall being most fond of?
What are your main health concerns?
When did you first experience these concerns?
Have any other family members had similar problems (describe)?
How have you dealt with these concerns in the past (doctors, self-care)?
What other health practitioners are you currently seeing?
What approach(s) has seemed to be the most effective in the past when dealing with health concerns?
List any medicine or supplements you are currently taking (this includes vitamins, minerals and herbs):
Please list the date and description of any surgical procedures you have had:
How often did you take antibiotics as a child?
How often did you take antibiotics as a teen?
How often did you take antibiotics as an adult?
Are there any foods that you avoid because of the way they make you feel: If yes please name the food and the symptom:
Do you have symptoms like bloating, gas, sneezing or hives immediately after eating? If so please explain:
Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so please explain:
Are there any foods that you consistently crave? If so please explain when and how often?
Do you have any known food allergies or sensitivities?
Which of the following do you consume regularly?
Soda
Diet Soda
Refined Sugar
Alcohol
Fast Food
Gluten (wheat, rye, barley)
Dairy (milk, cheese, yogurt, etc.)
Are you currently on a special diet?
Vegan
Vegetarian
Ovo-lacto vegetarian
Dairy-free
Gluten-free
Paleo
Primal
Ketogenic
Raw
Other
If other diet, please describe:
Would you like to try any of the above diets? If so please list which one:
What is your daily intake of clear fluids/water? (in ounces or liters):
What percentage of your meals are home-cooked?
10-30%
30-50%
50-70%
70-100%
Do you like to cook?
When you do eat out at restaurants, where do you like to eat/what type of food do you prefer?
Is there anything else that I should know about your current diet, history or relationship with food?
Please check any of the following conditions that apply to your history:
Diabetes
High Cholesterol
Cancer
Heart Disease
Hepatitis
STD’s
High Blood Pressure
Kidney Disease
Thyroid Disease
Depression
Asthma
Allergies
Anemia
Chronic Yeast Infections
Other
If other, please describe:
Briefly describe your symptoms, chosen treatment(s) and dates:
Bowel Movement Frequency
1—3 times per day
More than 3 times per day
Not regularly every day
Bowel Movement Consistency
Hard and difficult to pass
Well-formed
Lose
Diarrhea
Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum or chronic air pollution)?
Do you drink filtered or tap water? If filtered, please describe type of filter:
Are you ever exposed to second hand smoke?
Do you have any mercury amalgam fillings?
Are you sensitive to odors?
Describe any periods of eating junk food, binge eating or dieting:
List any addictive behaviors (past or present use and abuse of alcohol, drugs, tobacco, caffeine, workaholic, etc.):
How do you handle stress?
How is your sleep? Can you get to sleep easily? Can you stay asleep? And about how many hours of sleep do you get a night on average?
How were/are your menses? Do/did you have PMS? Painful periods? Please explain:
Have you experienced any yeast infections or urinary tract infections? Are they regular?
Are you on a hormonal birth control pill? If so please list type and how long you have been on it for:
Have you had any problems with conception or pregnancy?
Are you taking any hormone replacement therapy or hormonal supportive herbs? If so please list:
How are your moods in general?
Do you experience more anxiety and stress that you wish? Depression? Anger?
On a scale from 1-10 (1 being mild and 10 being very stressed) what would you say your level of stress is right now? (check one)
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10 (1 being low energy and 10 being high energy), describe your usual level of energy (check one):
1
2
3
4
5
6
7
8
9
10
Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Please explain:
Who out of your friends and family will be the most supportive and why?
What is the most motivating factor for you, to improve diet, health and lifestyle?
NUTRITION DISCLAIMER
*
The nutrition advice given by Blue Coast Nutrition (which hereafter refers to: Jennifer Spithill, NC) is solely based on the information provided by the client/individual. The nutrition information given is meant only for the client/individual completing the nutrition questionnaire form. It is the sole responsibility or the client/individual to provide complete and accurate information. Blue Coast Nutrition will not be liable for the effects of a nutrition assessment and/or advice based on any misrepresentation, misinformation, inaccuracy or omitted information. Blue Coast Nutrition provides nutrition counseling and is not licensed to prevent, diagnose, alleviate, or treat any medical conditions, disease, physical or mental ailments or pain or infirmities.
NUTRITION WAIVER & COVENANT NOT TO SUE
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I do here and forever release and discharge and hereby hold harmless Blue Coast Nutrition and their respective agents, heirs, assigns, contractors and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out or connected with my participation in any nutrition or lifestyle coaching including any injuries resulting there from. I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this program. I understand that results are individual and may vary.
CONSENT
*
I understand that my signature is confirming that I acknowledge and agree to be bound by the terms and conditions of this agreement.
Signed Name
*
First Name
Last Name
Signed Date
*
MM
DD
YYYY