Name
*
First Name
Last Name
Today's Date
*
MM
DD
YYYY
Height
*
Weight
*
What is your major complaint?
Other Complaints?
Blood Pressure
Body Fat Percentage
Current medications
Please list any medications, nutritional supplements or vitamins you are presently taking, along with when you began taking them.
Antibiotics
In the past, have you used antibiotics? If so, when and for how long?
Health Conditions
If you presently or have ever had any of the conditions listed below, check them. If not, check "None of these"
Surgeries
Please list all surgical procedures (including oral, out-patient and sutures) along with date or year. If none, then please write "none".
Hospitalizations
Please include all long and short-term hospitalizations along with the date or year these occurred. If none, then write "none".
Briefly describe where you have lived since childhood
Do you purchase organic fruits and vegetables or whole grains?
Check however many apply.
Do you purchase hormone-free or grass-fed or free-range meat and poultry?
Check any that apply.
How much sleep do you get each night?
1-2 hrs
2-3 hrs
3-5 hrs
6-7 hrs
8+ hrs
When do you typically go to bed?
Hour
Minute
Second
AM
PM
When do you typically wake up?
Hour
Minute
Second
AM
PM
Do you wake up in the middle of the night?
Yes
No
Do you have difficulty falling asleep?
Yes
No
Do you have difficulty waking up in the morning?
Yes
No
Do you smoke or drink alcohol or use recreational drugs?
Check however many apply
How often do you drink caffeinated beverages?
None
1-2 per day
3-5 per day
5+ per day
If yes, please list the food(s) and why it is restricted from your diet.
Cravings
For example: chips, nuts, cheese (dopamine)
Sugar or chocolate (Seritonin), bread
On average how much water do you drink a day?
Do you have breakfast every morning?
Yes
Sometimes
Never
Approximate Time
Hour
Minute
Second
AM
PM
Examples
Do you have a snack before lunch?
Always
Sometimes
Never
Approximate Time
Hour
Minute
Second
AM
PM
Examples
Do you have lunch every day?
Yes
Sometimes
Never
Approximate Time
Hour
Minute
Second
AM
PM
Examples
Do you have a snack before dinner?
Always
Sometimes
Never
Approximate Time
Hour
Minute
Second
AM
PM
Examples
Do you have dinner every day?
Yes
Sometimes
Never
Approximate Time
Hour
Minute
Second
AM
PM
Examples
Do you eat a snack at night?
Always
Sometimes
Never
Approximate Time
Hour
Minute
Second
AM
PM
Examples
Please explain any instances
What do you feel triggered the weight fluctuation?
Check all that apply
Was your weight gain or loss
Sudden
Gradual
Problem since childhood
Please list any close relatives that have diabetes heart disease or obesity
Write none if none.
What methods have you tried to lose or gain weight?
Are you currently pregnant?
Yes
Maybe
No
Date of last period
MM
DD
YYYY
Date of last breast exam
MM
DD
YYYY
Date of last pap smear
MM
DD
YYYY
Birth Control
Are you currently or have you ever used birth control pills? If so, when and for how long?
Do you suffer from PMS or cramping during your cycle?
Yes
No
Are you peri or postmenopausal and suffer from hot flashes or other symptoms?
Yes
No
Date of last prostate exam
MM
DD
YYYY
Date of last physical
MM
DD
YYYY
Date of last blood test
MM
DD
YYYY
How is your energy level?
What times int he day do you feel best?
What times in the day do you feel worst?
How do you deal with your stress?
A snack helps me feel better if I am feeling down
Yes
No
I sometimes have a hard time going to sleep without a bedtime snack
Yes
No
I get tired and or hungry mid-afternoon
Yes
No
I get a sleepy or drugged feeling after eating a meal containing bread or pasta or dessert
Yes
No
Now and then I think I am a secret eater
Yes
No
I almost always eat too much bread before a meal is served when at a restaurant
Yes
No
I have difficulty concentrating or have frequent fuzzy or spacey thinking patterns
Yes
No
I experience cravings for sugar or breads or pasta or baked goods
Yes
No
I feel shakey if I do not eat on time or if I do not have a snack
Yes
No
I often find myself irritable or angry
Yes
No
Are you happy in your life now?
Yes
No
My life used to be
Check all that apply
My life is currently
Check all that apply
I used to worry over
Check all that apply
I currently worry over
Check all that apply
I used to often
Check all that apply
I often
Check all that apply
In the past I
Check all that apply
Recently I have or currently I am
Check all that apply
Check any of the following that have applied to you in the last 30 days
In your estimation how physically fit are you right now?
Unfit
Below average
Average
Above average
Very fit
How often do you exercise?
What is your regimen?
What types of exercise have you enjoyed in the past?
Fitness goals
Check all that apply
