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Nutrition Intake History

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Nutrition Intake History NUTRITION INTAKE HISTORY Date Patient Information Patient Address Apt. Age Sex: M F City State Zip Home # Work # Ext. Birthdate Cell Phone # Patient SS# E-Mail Single Married Separated Divorced Widowed Best time and place to reach you IN CASE OF EMERGENCY, CONTACT Name Relationship Home Phone Work Phone Ext. Whom may we thank for referring you? Work Information Occupation Phone Ext. Company Address Spouse Information Name SS# Birthdate Occupation Employer I verify that all information within these pages is true and accurate. _____________________________________ _________________________________________ _____________________ Patient's Signature Patient's Name - Please print Date Health History Height Weight Number of Children Are you recovering from a cold or flu? Are you pregnant? Reason for office visit: Date started: Date of last physical exam Practitioner name & contact Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis, saliva, bone density): Outcome What types of therapy have you tried for this problem(s)? Diet modification Medical Vitamins/minerals Herbs Homeopathy Chiropractic Acupunture Conventional drugs Physical therapy Other List current health problems for which you are being treated: Current medications (prescription and/or over-the-counter): Major hospitalizations, surgeries, injuries. Please list all procedures, complications (if any) and dates: Year Surgery, illness, injury Outcome Circle the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest): 1 2 3 4 5 6 7 8 9 10 Identify the major causes of stress (e.g., job change, family status change, work related, finances, etc..) Do you consider yourself: Underweight Overweight Just right Your weight now: Have you had an unintentional weight loss or gain of 10 pounds or more in the last 3 months? Yes No Is your job associated with potentially harmful chemicals (e.g., pesticides, radioactivity, solvents) or health and/or life threatening activities (.e.g, fireman, farmer, miner)? Corrective lenses Dentures Hearing aid Medical devices/prothetics/implants, describe: Recent changes in your ability to: See Hear Taste Smell Feel hot/cold sensations Move around (sit upright, stand, walk, run, pick up things, swing your arms freely, turn your head, wiggle fingers) Strong like for any of the following flavors: Sour Bitter Sweet Rich/Fatty Spicy/Pungent Salty Strong dislike for any of the following flavors: Sour Bitter Sweet Rich/Fatty Spicy/Pungent Salty Do you: Prefer warmth (i.e. foods, drinks, weather, ect…) Prefer cold (i.e. foods, drinks, weather, ect…) N/A Is your sleep disturbed at the same time each night? If yes, what time? Time of day you feel the most energy or the least symptoms: Time of day you feel the worst or your symptoms are aggravated: 6:00 am - 12:00 pm 6:00 pm - 12:00 am 6:00 am - 12:00 pm 6:00 pm - 12:00 am 12:00 pm - 6:00 pm 12:00 am - 6:00 am 12:00 pm - 6:00 pm 12:00 am - 6:00 am Do you experience any of these general symptoms EVERYDAY? Shortness of breath Nausea Fecal incontinence Bleeding Insomnia Headaches Vomiting Urinary incontinence Discharge Constipation Dizziness Diarrhea Low grade fever Itching/rash Chronic pain/inflammation Medical History Health Habits Current Supplements Arthritis Decreased sex drive Tobacco: # per day __________ Multivitamin/mineral Allergies/hay fever Infertility Alcohol: Vitamin C Asthma Sexually transmitted disease Wine: # glasses/d or wk ____________ Vitamin E Alcoholism Other ____________________________ Liquor: #oz./d or wk _______________ EPA/DHA Alzheimer's disease Medical (Women) Beer: # glasses/d or wk ____________ Evening primrose/GLA Autoimmune disease Menstrual irregularities Caffeine: Calcium, source ______________________ Blood pressure problems Endometriosis Coffee: # 6oz. Cup/day _____________ Magnesium Bronchitis Infertility Tea: # 6oz. Cup/day _______________ Zinc Cancer Fibrocystic breasts Soda: # cans/day _________________ Minerals, describe ____________________ Chronic fatigue syndrome Fibroids/ovarian cysts Other ___________________________ Friendly flora (acidophilus) Carpal tunnel syndrome Premenstrual syndrome (PMS) Water: # glasses/day _________ Digestive enzymes Cholesterol - elevated Breast cancer Amino acids Circulatory problems Pelvic inflammatory disease Exercise CoQ10 Colitis Vaginal infections 5 - 7 days per week Antioxidants (eg, lutein, resveratrol, etc.) Dental problems Decreased sex drive 3 - 4 days per week Herbs - teas Depression Sexually transmitted disease 1 - 2 days per week Herbs - extracts Diabetes Other ____________________________ 45 min or more duration/wk Chinese herbs Diverticular disease Age of first period __________________ 30 - 45 min duration/workout Ayurvedic herbs Drug addiction Date of last gynecological exam ________ Less than 30 min Homeopathy Eating disorder Mammogram + - Walk Bach flowers Epilepsy PAP + - Run, Jog, jump rope Protein shakes Emphysema Form of birth control ______________ Weight-lift Superfoods (eg. Phytonutrient blends) Eyes, ears, nose, throat problems # of children _______________________ Swim Liquid meals Environmental sensitivities # of pregnancies ___________________ Box Other_____________________________________ Fibromyalgia C-section ___________________ Yoga Food intolerance Surgical menopause Other ______________________ Would you like to: Gastroesophageal reflux disease Menopause Nutrition & Diet Have more energy Genetic disorder Date of last menstrual cycle ________ Mixed food diet (animal & veg) Be stronger Glaucoma Length of cycle _______ days Vegetarian Have more endurance Gout Interval between cycles ______ days Vegan Increase your sex drive Heart disease Recent changes in normal menstrual flow Salt restriction Be thinner (e.g., heavier, large clots, scanty) _______ Inflammatory bowel disease Fat restriction Be more muscular Irritable bowel syndrome Family Healthy Starch/carbohydrate restriction Improve your complexion Kidney or bladder disease History Total calorie restriction Have stronger nails Learning disabilities Arthritis Specific food restrictions: ___________ Have healthier hair Liver or gallbladder disease (stones) Astma _______________________________ Be less moody Mental illness Alcoholism Other __________________________ Be less depressed Migraine headaches Alzheimer's disease Feel more motivated Neurological problems Cancer Food Frequency Be more organized (Parkinson's, paralysis) Servings per day: Sinus problems Depression Fruits (citrus, melons, etc.) ___________ Thisnk more clearly; be more focused Stroke Diabetes Dark green or deep yellow/orange Improve memory Thyroid trouble Drug addiction vegetables _________ Do better on tests Obesity Glaucoma Grains (unprocessed) _______________ Not be dependent on over-the-counter meds like aspirin, ibuprofen, sleeping aids, etc Osteoporosis Heart disease Beans, peas, legumes ______________ Stop using laxatives or stool softeners Pneumonia Infertility Dairy, eggs ______________________ Be free of pain Sexually transmitted disease Learning disabilities Meat, poultry, fish _______________ Sleep better Seasonal affective disorder Mental illness Have agreeable breath Skin problems Mental retardation Eating Habits Have agreeable body odor Tuberculosis Migraine headaches Skip breakfast Have stronger teeth Ulcer Neurological disorders Two meals/day Get less colds and flus (Parkinson's, paralysis) Urinary tract infection Obesity One meal/day Get rid of your allergies Varicose veins Osteoporosis Graze (small frequent meals) Reduce your risk of inherited disease tendencies (eg. cancer, heart disease, etc..) Other ____________________ Stroke Food rotation Suicide Eat constantly (hungry or not) Medical (Men) Benign prostatic hyperplasia (BPH) Other _______________________ Eat on the run Prostate cancer ____________________________ Add salt to food Systems Survey Form | Restricted to Professional Use WHOLE FOOD NUTRIENT SOLUTIONS name: DATE OF BIRTH: EMAIL:__________________________ date: INSTRUCTIONS: Circle the number that applies to you. If a symptom does not apply, don’t circle anything for that symptom. Circle the corresponding number. 1 MILD symptom (occurs rarely) 2 MODERATE symptom (occurs several times a month) 3 SEVERE symptom (occurs almost constantly) GROUP 1 45. 1 2 3 Get “shaky” if hungry 85. 1 2 3 Discomfort between 1. 1 2 3 Acid foods upset 46. 1 2 3 Fatigue, eating relieves shoulder blades 2. 1 2 3 Get chilled often 47. 1 2 3 “Lightheaded” if meals delayed 86. 1 2 3 Occasional laxative use 3. 1 2 3 “Lump” in throat 48. 1 2 3 Heart palpitates if meals missed 87. 1 2 3 Stools alternate from soft 4. 1 2 3 Dry mouth, eyes, nose or delayed to watery 5. 1 2 3 Pulse speeds after meal 49. 1 2 3 Fatigue in afternoon 88. 1 2 3 Sneezing attacks 6. 1 2 3 Keyed up, fail to calm 50. 1 2 3 Overeating sweets upsets 89. 1 2 3 Dreaming, nightmare-type 7. 1 2 3 Gag occasionally 51. 1 2 3 Awaken after few hours sleep, bad dreams 8. 1 2 3 Unable to relax, startle easily hard to get back to sleep 90. 1 2 3 Bad breath (halitosis) 9. 1 2 3 Extremities cold, clammy 52. 1 2 3 Crave candy or coffee in afternoon 91. 1 2 3 Milk products cause upset 10. 1 2 3 Strong light irritates 53. 1 2 3 Moods of “blues” or melancholy 92. 1 2 3 Sensitive to hot weather 11. 1 2 3 Occasionally weak urine flow 54. 1 2 3 Craving for sweets or snacks 93. 1 2 3 Burning or itching anus 12. 1 2 3 Heart pounds after retiring 94. 1 2 3 Crave sweets TOTAL 13. 1 2 3 “Nervous” stomach 1 2 3 TOTAL 14. 1 2 3 Appetite reduced occasionally 1 2 3 15. 1 2 3 Cold sweats often GROUP 4 16. 1 2 3 Get heated easily 55. 1 2 3 Hands and feet go to GROUP 6 17. 1 2 3 Nerve discomfort sleep easily, numbness 95. 1 2 3 Loss of taste for meat 18. 1 2 3 Staring, blink little 56. 1 2 3 Sigh frequently, “air hunger” 96. 1 2 3 Lower bowel gas several hours 19. 1 2 3 Sour stomach frequent 57. 1 2 3 Aware of “breathing heavily” after eating 58. 1 2 3 High-altitude discomfort 97. 1 2 3 Burning stomach sensations, TOTAL 1 2 3 59. 1 2 3 Open windows in closed room eating relieves 60. 1 2 3 Immune system challenges 98. 1 2 3 Coated tongue GROUP 2 61. 1 2 3 Afternoon “yawner” 99. 1 2 3 Pass large amounts 20.
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