Nutrition Questionnaire

This office deals with the health, vitality and longevity of the individual. The following questions will help us to more accurately design a personalized program to allow you to reach your maximum health potential. Thank you for completing this form in its entirety and sending it back to [email protected] at least one week before your appointment. Name (Last, First, MI) Social Security Number

Birthdate Gender Marital Status Home Phone M S D

Address Cell Phone

Work Phone

Email Address □ Do not use email to contact me

Employer and Job Title Avg. number of hours per week spent working:

Emergency Contact Name Contact Phone Referred by

Personal Physician’s Name Physician’s Phone

Preferred Pharmacy Name Pharmacy Phone

GENERAL INFORMATION Reason for consultation: ______Desired outcome of consultation: ______What have you tried in the past to address your concerns that did not work: ______Have you experienced any of the following recently (check all that apply):

 Anxiety  Brain fog  Constipation  Depression  Diarrhea  Dizziness/tingling  Fatigue  Fluid retention  Headaches  Irritability  Joint pain  Muscle loss  Sinus/allergy issues  Sleep disturbance  Sore muscles  Sugar cravings  Swollen hands/feet  Weight gain  Weight loss (unwanted)  Other (please explain) ______

How important is it for you to resolve your health concerns on scale of 1-10 (1 being lowest)? 1 2 3 4 5 6 7 8 9 10 How prepared/motivated are you to make the appropriate lifestyle changes that may be necessary in order to achieve your goals (1 being lowest)? 1 2 3 4 5 6 7 8 9 10

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Are you currently under the care of a healthcare professional for a medical/health condition:  No  Yes

If yes, please describe condition(s): ______

Please check any medical condition or health problems that you currently have or have had in the past:

Condition Yes No Condition Yes No

HeadachesHeart Disease (Migraines) SeizureChest Disorder Pain RecurrentIrregular Sinus Heartbeat Infections SeasonalHigh BloodAllergies Pressure Emotional/PsychiatricBlood Clotting Problems Illness DepressionBleeding Disorder Anxiety/ExcessiveStroke/Vascular Stress Disease AsthmaConstipation/Diarrhea ChronicHepatitis/Liver Bronchitis Disease Lung/BreathingKidney Disease Problems ChronicMenstrual Indigestion Disorders StomachReproduction Ulcers Problems IntestinalProstate Disease Problems Skin Sexual/LibidoProblems Problems BackT Pain/Sciaticaendonitis HerniatedChronic Disc Pain NeckShoulder Pain Problems ChronicOsteoarthritis Muscle/Joint Pain CarpalRheumatoid Tunnel Syndrome Arthritis FibromyalgiaArtificial Joint(s) DiabetesCancer ThyroidPsoriasis Disease or Eczema Osteoporosis/OsteopeniaOther (please list below)

List any additional health problems not listed above:

List any surgeries/operations you have had and when: ______

Preventative Tests Month/Year of Last Test Test Results

Cholesterol

Vitamin/Mineral Test

Thyroid

ww w .womensspecialtyhealthca r e.co m • ww w .specialtyhealthca r eandwellness.com FAMILY HISTORY For the conditions listed below, check Yes or No if anyone in your family has been affected, then please note your relationship to that relative with that condition/disease on the adjacent line.

Condition Yes No Relationship Autoimmune condition(s) Breast cancer Diabetes (Type 2) Colon cancer Heart disease Hypertension Ovarian/uterine cancer Prostate cancer Skin disorders Thyroid disease (hypo/hyper/hashimotos) Other cancer

List any other disease/condition in your family and the relationship: ______

______

FEMALE PERSONAL HISTORY

Are you still menstruating? First day of last menstrual cycle? Do you have bleeding between periods?

Are you pregnant? Have you ever been pregnant? How many pregnancies?

Have you had a hysterectomy? Tubal Ligation? Do you still have your ovaries?

Are you currently taking any hormones/oral contraceptives? Have you had any issues with them? ______

Do you have uterine fibroids? ______Endometriosis? ______Menstrual irregularities? ______

Date of last PAP smear Result Clinic / Doctor Name

Date of last Mammogram (if applicable) Result Place performed

MALE PERSONAL HISTORY

Date of last physical: ______Result ______Clinic / Doctor Name ______

Date of last prostate exam: ______Result ______Clinic / Doctor Name ______

Are you concerned with a loss of muscle mass, tone or strength?  No  Yes

Have you had problems with urination (decreased stream/frequent night urination)?  No  Yes

Has your abdominal girth and weight been increasing?  No  Yes

Do you have a desk job?  No  Yes

Have you been told you have “low testosterone”?  No  Yes

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List current medications (or those you have taken within the last year).

Medication Name Date Started Date Stopped Dosage (amt /# daily)

Nutritional supplements, vitamins, herbs, homeopathic remedies taken:

Medication Allergies:

Environmental/Food Allergies:

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What are the challenges that prevent you from improving your diet and health?

Tobacco:  I have never smoked.  I quit smoking in ______(mo/yr). I smoked ______packs/day for ______years.  I use other tobacco products.  I currently smoke ______packs/day. I have smoked for ______years.

Alcohol:  I never drink alcohol.  I have a family history of alcoholism.  I occasionally drink alcohol.  I drink ______drinks per day/week/month (circle one).

Diet: How many meals per week are consumed from fast food restaurants?

How many meals per week are consumed from regular (not fast food) restaurants?

How many alcoholic beverages do you have per week?

How many sodas (diet or regular) do you consume per week?

How many servings of refined sugar do you have per week? (desserts, candy, chocolate, sodas, etc) One serving equals about 100 calories.

What are the three healthiest foods you eat each week: ______

______

What are the three worst foods you eat each week: ______

______

Please list any dietary restrictions/preferences you have:______

______

Exercise: I routinely exercise _____ hours ______times per week.

Please describe your current exercise routine, if you have one:

Sleep: In my bedroom (check all that apply): On weekdays I go to bed at ______and I am likely asleep by ______ I use an alarm clock On weekdays my alarm goes off at ______and I get out of bed at ______On weekdays I wake up ______times per night  I watch TV before going to sleep

 I use phone/computer to surf the web On weekends I go to bed at ______and I am likely asleep by ______ I read a paper book On weekends my alarm goes off at ______and I get out of bed at ______On weekends I wake up ______times per night  I read on an electronic device

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Name:______Date:______

Write down everything you eat, drink and take (supplements and medications) for three days, including all snacks, beverages, and water. Please include approximate amounts. If you notice any mood or digestive changes associated with a meal/snack, record it in the right-hand column.

Meal Beverages Mood/ Supplements/ Digestive Changes Medications Breakfast (Time:______)

Snacks (Time:______)

Lunch (Time:______)

Dinner (Time:______)

Bowel Movement(s): (Time:_____) (Time:_____) (Time:_____) (Time:_____)  Normal  Loose /diarrhea  Hard  Undigested food in stool  Small pellets  Painful  Urgent  S-Curve, formed  Fatty, floating  Lumpy  Soft

Sleep Pattern: I went to bed at _____ and I was likely asleep by _____. I woke up at _____ and got out of bed at _____. I woke up ____ times last night. I felt ______before bed (ex. anxious, exhausted).

Cravings: Today I had cravings for: ______at ______am/pm Today I had cravings for: ______at ______am/pm

Exercise: Today I exercised for _____ minutes. The kind of exercise I did was: ______.

Name:______Date:______

Lunch (Time:______)

Name:______Date:______

Lunch (Time:______)

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