Healing To The Core


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Health and Diet History

Personal Information

First Name:
Initial:
Last Name:
eMail Address:
 
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
 
Occupation:
Age:
Marital Status
 
Number of Children:
List your children's names, gender and age.

Health History

Height:
Weight (lbs)
Eye color
Hair color
 
Current Health
Age 0-12 Age 12-21
Age 21-30 Age 30-40
Age 40-50 Over 50
 
Usual Energy Level:

How much daily energy do you usually have without consuming stimulants like sugar or caffeine?

 
Usual Activity Level:
How much exercise, cardiovascular or aerobic (e.g., walking, running) or strength training, do you routinely achieve weekly?
 
Major and minor disorders/diseases or ailments you've had in your lifetime (ranging from heart disease, cancer & arthritis to indigestion, headaches, arthritis, hormonal imbalances, weight gain or loss, etc.)

Please list in chronological order from childhood to present and explain how severe and/or chronic these are.

 
Women Only:
Have you had a hysterectomy?
 
Are you now, or have you ever taken hormones or HRT?
Name of hormone?
How long taken?
 
What medications are you currently taking? What medications have you taken in the recent past?
 
Do you have any current medical ailments, disorders or complaints?

Diet History

How would you characterize your eating habits?
 
Do you eat any of these fairly regularly:
Refined Sugar (candy, cookies, desserts, etc.)
Caffeine (coffee, tea, soft drinks, chocolate)
Snack/Junk Foods (Processed, pre packaged and snack foods)
High Fat Foods (Sauces, gravies, greasy or fried foods)
 
Do you drink at least 8 glasses of plain water each day. (Not soft drinks or coffee, but plain water.)
 
Do you eat a good amount of fresh, healthy food daily? Please check the foods below that you eat on a fairly regular basis.
Fruit
Vegetables
Salads
Lean Chicken
Lean Beef
Fish
Pork
Lamb
Eggs
Milk
Cheese
Yogurt
Breads
Potatoes
Other Starches (list below)
 
What other foods do you typically eat or enjoy eating regularly:
 
When you treat yourself, what do you usually eat?
Sweets
Ice Cream
Starchy or salty foods like chips
Healthy foods (nuts, fruits, cheese)
 
Do you smoke cigarettes?
Do you drink alcohol?
 
In addition to the medications above, what medications, prescription drugs, over the counter drugs, vitamins and herbal supplements are you currently taking?
 
Which of these apply to you?

I have cravings for sweets or fatty foods   
I sometimes still feel hungry after meals
I get indigestion, heartburn, gas or constipation

Check all that apply
Hearburn
Nausea
Acid stomach
Gas
Constipation
 
I get very sleepy or dull witted between meals or mid-afternoon

 
What are your current goals in seeking health/nutritional counseling?
 
Give an example of one of your most typical day's meals below. List the typical way you would eat without having to “clean it up” for me. Please be honest! Include junk food, snacks, beverages, and skipping meals if that is your routine.
 
Typical Breakfast
 
Typical Snack
 
Typical Lunch
 
Typical Snack
 
Typical Dinner

Other

What else would you like me to know?

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