Name: Date: Address: Email: Phone: Age/DOB: Ht: Referred by: Recent Wt: Desired Wt: Highest Wt: Wt 1 yr ago:

NUTRITION QUESTIONNAIRE What are your goals / changes you would like to see?

Have you tried before to reach these goals? ▪ If so, what worked/what didn’t?

Health History: (check and put diagnosis year by all that apply) Allergies Eczema, psoriasis, dermatitis High cholesterol Anemia Epilepsy/seizures High triglycerides Anxiety / Depression Fibromyalgia Hypoglycemia Arthritis: ______Food allergy/sensitivity Kidney disease/stones Asthma Fungal infections Lung disease Autoimmune: ______Gallbladder issues/removal Liver disease Cancer Gout Osteoporosis Chronic fatigue Heart disease/attack PCOS Crohn’s or Ulcerative colitis Heartburn/reflux Thyroid disease Diabetes: ______High blood pressure Other: ______

Family history of any of the above? Please list:

List current treatments / medications you are taking: ______

How many times in the past year have you taken antibiotics? ______In the past 5 years? ______

What supplements do you take? (check all that apply) Multivitamin Vitamin D Calcium Other: ______Fish Oil Vitamin C Magnesium Other: ______Probiotic B Vitamins Other: ______Other: ______

List dietary limitations, food allergies or sensitivities that you are aware of: ______

What do you typically eat for… Breakfast: Lunch: Supper: Snacks: Beverages: How often do you eat out? ______Who does the shopping and preparation for meals? ______Does a meal or snack typically hold you at least 3 hours? Y / N Are your family/friends supportive of you making changes? Y / maybe / N / not sure Current exercise habits and limitations: ______

What are your fitness goals (if any): (Check all that apply) General fitness Muscle toning Weight loss/maintenance Muscle strengthening Specific sport enhancement ______Body building Flexibility and balance Other: ______

Rate level of stress from 1 (extremely low) to 10 (extremely high): ______

What helps you unwind / relax? ______

Female: (check any that apply) Pregnant Menopausal Cramps Trying to get pregnant Hot flashes Breast tenderness Breastfeeding Night sweats Digestive issues during period Menstrual irregularity Headaches Recurrent yeast infections

HOW OFTEN DO YOU EXPERIENCE THE FOLLOWING: (1= SELDOM, 2= OFTEN, 3=ALWAYS)

1 2 3 1 2 3 Food cravings (sweet, salty, fast food) Bad breath Not satisfied after eating Excessive burping Eat while reading, tv, computer etc. Heartburn/Reflux Always think about food Gassy following a meal Lose motivation quickly Bloating/Fullness in gut Constipation Daily stress level is high Diarrhea Sleep less than 7 hours/night Less than 1 bowel movement/day Difficulty falling asleep Nausea/Vomiting Struggle with energy levels Stomach pain Need caffeine to start day Intestinal pain / discomfort Drop in energy soon after eating Fungal infections (athlete’s foot, yeast infections etc)

Skin conditions (eczema, acne, Skip meals dermatitis, psoriasis) Muscle/Joint Pain Irritable / shaky if meals missed Catch colds/illnesses Mental fog/sluggishness Sinus drainage / excess phlegm Headaches/Migraines Bags / dark circles under eyes Depression/Anxiety

Symptom Questionnaire Name: Date: Rate each symptom based on what has been typical for you Notes: for the last 30 - 60 days Blank = Never or rarely 1 = Occasional, not severe(1 time per week or less) 2 = Occasional, severe (1 time per week or less) 3 = Frequent, not severe (2+ times per week) 4 = Frequent, severe (2+ times per week) Energy / Activity Nasal / Sinus Joint / Muscle Fatigue (sluggish, tired) Post nasal drip Joint aches / pains Restless(can’t relax/sit still) Sinus pain Stiff joints Daytime sleepiness Runny nose Muscle aches / pains Insomnia at night Stuffy nose Stiff muscles Malaise (feeling lousy) Sneezing Muscle spasms or cramps Hyperactivity Excess mucus Weak / fatigued muscles TOTAL: TOTAL: TOTAL: EMOTIONAL/MENTAL MOUTH/THROAT CARDIOVASCULAR Depression Dry mouth Irregular heartbeat Anxiety (fears, uneasiness) Sore throat / hoarseness Rapid heartbeat (tachycardia) Mood swings(rapid chgs) Swelling / burning lips High blood pressure Irritability Cracked corners of mouth TOTAL: Forgetfulness Throat clearing/phlegm DIGESTIVE Poor concentration Canker sores Heartburn/reflux Brain fog TOTAL: Stomach pains/cramps TOTAL: LUNGS Intestinal pains/cramps NEUROLOGICAL Asthma, bronchitis Constipation Migraine Chest congestion Diarrhea Headache Dry cough Painful elimination Dizziness or vertigo Wet cough Bloated feeling Faintness / Lightheaded Shortness of breath Belching, passing gas Seizures TOTAL: Nausea / Vomiting Insomnia EYES TOTAL: TOTAL: Red or swollen eyes WEIGHT SKIN Watery eyes Weight: Height: Rashes or hives Dry, Itchy eyes Fluctuating weight Eczema or psoriasis Dark circles or “bags” Food cravings Flushing / Hot Flashes Sensitivity to light Water retention Itchy skin TOTAL: Binge eating or drinking Acne EARS Purging (all methods) TOTAL: Earache TOTAL: GENITOURINARY Ear infection OTHER SYMPTOMS: Painful urination Ringing in ears/ hearing loss Frequent illness Bladder pain Itchy ears Frequent Urination Drainage from ears TOTAL: TOTAL: TOTAL:

Digestive Assessment (Check all that apply)

Food Triggers Bacterial Imbalance (Dysbiosis)

Constipation or sluggish bowels Crave bread, sugar, or alcohol (< 1 bowel movement/day) Been told I have SIBO (Small intestinal Take meds for reflux or acid bacterial overgrowth) indigestion, digestive enzymes or Have yeast overgrowth (candida) other supplements to digest food Chronic yeast infections I often have a drop in energy or feel Indigestion with fatty foods “drugged” after eating Been told I have leaky gut Have known food sensitivities Incomplete bowel movements (don’t Migraine Headaches feel cleaned out) Been diagnosed with insulin Taken antibiotics > 1x in last 3 years resistance, metabolic syndrome, or Frequently had antibiotics up to age 20 diabetes or recently Loose stools often My symptoms started after a bout of Undigested food in stool at times food poising or travelers diarrhea. Crave sweets but have energy crash I’ve had food poisoning in past 5 years after eating Often get loose stools Bowels rotate back and forth from Drop in energy or feel “drugged” after constipation to diarrhea (or IBS) eating Hives, eczema, allergies, or asthma Undigested food in stools at times Heart races after certain foods Get full very quickly Cracks in the corner of mouth Nausea after eating Score: Often need antacids Known food sensitivities Symptoms when eat gluten or dairy Low Enzymes/HCL Seasonal allergies, food allergies, asthma, or eczema Skin rashes, hives, eczema after eating Depressed, moody, or irritable after certain foods eating certain foods Burp constantly Skin rash, hives, eczema after eating Frequent indigestion /feeling of food certain foods sitting in stomach Diagnosed with hashimoto’s Have Hashimoto’s Rheumatoid arthritis or other Take meds for reflux, acid indigestion, autoimmune disease digestives enzymes, or other Constipated or sluggish bowels (< 1 supplements to help with digestion bowel movement/day) Did not belch within 5 minutes of Take meds for reflux or acid baking soda test indigestion, digestive enzymes, or Score: other supplements to help digest food. Score:

Digestive Assessment Continued

Leaky Gut SIBO

Congestion or sneezing immediately Diagnosed with SIBO previously after eating Get full very quickly when eat Been told I have leaky gut Nausea after eating or at other times Taken antibiotics > 1x in past 3 years Bloated easily/abdominal Frequently had antibiotics up to age 20 distention/gas or recently Take meds for reflux, acid indigestion, Symptoms started after food poisoning digestives enzymes, or other or travelers diarrhea supplements to help with digestion Take Ibuprofen, other NSAID, or Feel like I have a bicycle inner tube Tylenol >1x/week under ribs after eating Had food poisoning in past 5 years Bloating, especially in upper digestive Known food sensitivities area after eating Symptoms when eat gluten or dairy Been on antibiotics recently and gut Have seasonal allergies, food allergies, symptoms went away while on asthma, or eczema antibiotics Canker sores often Score: Depressed, moody, or irritable after eating certain foods Skin rash, hives, or eczema after eating certain foods Diagnosed with Hashimoto’s, Rheumatoid arthritis or other Gut Imbalance Totals autoimmune disease Take meds for reflux, acid indigestion, Pattern Score digestives enzymes, or other Food Triggers supplements to help with digestion Low Enzymes / HCL Score: Bacterial Imbalance (Dysbiosis) Reflux/GERD Symptoms Leaky Gut Reflux/GERD Heartburn, GERD, reflux, acid SIBO indigestion Often need antacids Burning sensation in chest, sometimes throat or sour taste in mouth often Difficulty swallowing Dry Cough Often have a hoarse or sore throat Regurgitation of food or liquid Sensation of lump in throat Chest Pain Score: