Lifestyle Assessment Form

First and Last Name*

Your Email Address*

Your Phone Number*

Address

Date of Birth*

MM slash DD slash YYYY

Sex*

Male

Female

Thank you for taking the time to fill out this form as completely as possible. The more thorough you are, the better I will be able to understand your personal and health needs. I look forward to working with you. Please note that all of this information is confidential and honesty is the key to vibrant health!

What is your primary reason for this visit?

Please describe your current state of health:

If applicable, what types of treatments have you tried for your current health condition, if any?

Please list your health/nutrition concerns or other questions you would like to address in order of importance:

Have you experienced any major trauma in the past 5 years?

LIFESTYLE

What level of stress do you feel you are experiencing at this time? Please quantify on a scale of 1 (low) to 10 (high):

What are the major causes or factors of your stress?

How does your stress manifest itself?

Do you use any coping mechanisms?

What do you do for exercise? (indicate type, frequency, time of day and duration). Are you consistent with your exercise/activities?

How would you describe your energy levels?

Do you experience any lulls or highs in your energy levels throughout the day? If so, at what time of day?

How many hours on average do you sleep daily? (include naps)

What time do you typically go to sleep?

What time do you wake up?

Do you have trouble falling asleep?

Yes

Do you have trouble staying asleep?

Yes

If important, please share more details about your sleep:

What is your occupation?

How many hours do you work each day?

Do you enjoy your work?

Yes

Sometimes

Do you smoke?

Yes

For how low have you smoked, and how many daily?

Do you wish to gain weight? or lose weight?

Loose

Gain

Neither

If yes, how much weight want to gain or lose?

By when do you wish to reach your goal weight?

MM slash DD slash YYYY

What is your main motivation to change your weight?

How many hours do you spend daily, on average

Driving

Please enter a number from 0 to 18.

Reading

Please enter a number from 0 to 18.

Watching Television

Please enter a number from 0 to 18.

In front of computer

Please enter a number from 0 to 18.

What are your interests and hobbies?

MEDICAL HISTORY

Please list any medications you are currently taking and the reason(s) for each:

Have you taken antibiotics over the past five years?

Yes

Please list any vitamins, minerals, herbal or homeopathic remedies you are currently taking, as well as the dosages of each:

Please list any allergies or sensitivities.

Have you ever been diagnosed with an illness? If yes, please explain.

Have you ever been hospitalized or had surgery? If yes, please explain.

How often do you have a bowel movement?

Do you strain to have a bowel movement?

yes

sometimes

Related to any particular foods/circumstances?

Do you have loose bowel movements?

yes

sometimes

Related to any particular foods/circumstances?

Is there undigested food in your stool?

yes

sometimes

Related to any particular foods/circumstances?

Do you use recreational drugs? If yes, how often and what type?

FAMILY HISTORY

If applicable indicate: F=father, M=mother, GM=grandmother, GF=grandfather, S=sibling, O=other

Heart disease

Diabetes

Allergies

Arthritis

Gall bladder issues

Autoimmune

Asthma

Kidney dysfunction

Intestinal disease

Mental illness

Ulcers

Osteoporosis

Skin conditions

Hypertension

Alcohol/drug abuse

Cancer? what type?

Cancer

Other?

FEMALES

Are you or could you be pregnant?

Yes

Do you suffer from PMS symptoms? Please specify.

Have you noticed any changes in menses, for example the frequency, duration, flow, clotting, or other changes? If yes, please explain.

Are you:

Pre-menopausal

Menopausal

Are you experiencing menopausal symptoms?

Have you ever had a bone density test? What was the result?

DIETARY HABITS

How many main meals do you eat daily? include time.

How many snacks do you eat in a day? include time.

Do you eat meals:

with family

alone

on the run

fast food

restaurant

takeout

Do you feel there are restrictions to your diet due to preferences of others such as family, roommates, etc?

How many 1/2 cup servings do you eat of each in a typical day?

Fruit

Vegetables

Protein (detail type)

Whole grains

Dairy products (if yes, detail type)

Other (specify)

Provide examples of your typical meals:

Breakfast

Lunch

Dinner

Snacks (includes daytime snacks and evening if any)

Do you eat or use the following? Use 1 for rarely, 2 for regularly, or 3 for very often.

Margarine

Processed meat/Lunch meat

Fried foods

Refined grains (pastries, white bread, pasta)

Candy

Artificial sweetners/Spenda/Aspertame/Nutra Sweet

Refined grains (pastries, white bread, pasta)

Microwave

Please indicate how many cups of the following you drink per day:

Tap water

Filtered tap water

Spring or bottled water

Carbonated water

Tea (black/green)

Herbal tea

Coffee

Dairy milk

Juice (prepared)

Fresh fruit juice

Fresh veg juice

Beer

Red wine

White wine

Other alcoholic beverages

Soft drinks (regular)

Soft drinks (diet)

Other

Are you a:

Meat eater

Vegetarian

Vegan

How often do you eat meat?

Daily

3-5 days per week

1x per week

What are you favourite foods? how often do you eat them?

What foods do you crave ? how often do you eat them?

Are there any foods that you avoid? if yes, why?

Do you experience any symptoms if meals are missed? Explain:

Do you experience any symptoms after meals? Explain:

Additional comments:

CLIENT STATEMENT*

I agree

I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily.

All information contained on this form will be kept strictly confidential.

Name

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