Nutrition and Medical History Questionnaire NameEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Best Daytime PhoneAlternative PhoneDate of Birth Date Format: MM slash DD slash YYYY Marital StatusSingleMarriedDivorcedWidowedDatingSignificant otherOccupationIf applicable, number of children & age(s)Referred ByMedical History List any medical diagnosisList medications, vitamins & herbal preparationsDo you currently take a probiotic?YesNoIf yes above, what is your probiotic and when do you take it?ChallengesWhat is your biggest challenge right now?When did you first start to experience this challenge?What have you tried before to address this challenge?What is this challenge costing you, in your opinion?How important is changing this issue for you?Weight HistoryHeightCurrent WeightDesired WeightLowest Weight In Past YearHighest Weight In Past YearDo You Want To Lose/Gain/Maintain Weight?If Applicable, When (And How) Did Your Weight Gain Or Weight Loss Begin?For Weight Loss ClientsPlease tell me why you want to lose weightList Latest Lab Values, If Available and DateIronTIBCFerritinTransferrinB12GlucoseTotal cholesterolLDL cholesterolHDL cholesterolTriglyceridesASTALTVitamin DThyroid TSHTotal T4T3 UptakeT4 FreeAnti-Thyroglobulin ABProgesteroneTestosterone totalHomocysteineInsulin Like Growth Factor (IGF)C-PeptideLeptinHb-A1cCeliac Test ResultsBowel HabitsFrequency1 – 3 X DayMore Than 3 X DayNot Regularly EverydayDo you experience excessive intestinal gas?YesNoExercise HistoryDo you exercise?If no, why?Type of exerciseHow often?For how long?Describe other physical activitiesWhat kinds of circumstances interfere with physical activity?Choose the best description of your energy levelUsually energetic/occasionally tiredAverage energy/sometimes more energetic/sometimes more tiredFrequently tired/occasionally energeticAlways tired/no energySleep & Stress HabitsWhat time do you go to bed most nights?What time do you wake up most mornings?How many hours of quality sleep to you get most nights?Overall, would you classify your sleep as restful?YesNoDo you use your phone/computer/watch TV right before bed?YesNoDo you currently practice yoga?YesNoIf yes above, how often?Do you currently practice meditation?YesNoIf yes above, how often?How do you cope with stress in your life?Food Choice InventoryFood DislikesFood Allergies/IntolerancesDo you currently eat a gluten-free diet?YesNoIf yes above, how would you classify your gluten-free diet?100% gluten-freeMostly gluten-free but some gluten foods occasionallyDo you currently consume dairy?YesNoIf yes above, what type(s) of dairy? milk cheese yogurt cottage cheese ice cream other Meal PlanningHow Many People In Your Household?Who Plans Meals?Who Cooks?Who Shops?Is A Shopping List Used?Dining OutHow Often Do You Eat Out Each Week?What Meals?Where?How Many Times Each Week Do You Eat At A Fast Food Restaurant?Where?BeveragesDo You Drink Alcohol?YesNoTypesWeekly AmountDo You Drink Coffee/Tea?YesNoRegular Or Decaf?Daily AmountOther Beverages?Daily AmountFood HabitsDo You Skip Meals?If Yes, What Meals And Why?Do You Crave Certain Foods?What? / When?Do You Eat Before Bedtime?What?What Do You Feel Are Your Worst Eating Habits?Do you practice Intermittent Fasting (IF)?YesNoIf you practice IF, what form?12:1216:818:65:224 hour or 36 hourLonger or other patternAre you interested in learning more about IF?YesNoUnsure/MaybeWhat Is Your Current Diet Like? List What You Generally Eat For:BreakfastLunchDinnerSnacksBeveragesAlso, List Approximate Times You Eat:BreakfastLunchDinnerSnacksDo you eat when you are: Standing Up In The Car Watching Tv Reading Or On Computer With Others Fast Bored Stressed Anxious Lonely Hungry Not Hungry Allergy HistoryDo You Have Any Known Food Or Environmental Allergies?List All Foods, Additives, And Medications That You Know Or Suspect You Are Allergic To:Do you have any expectations from speaking with Caitlin or specific things you hope to get out of your time with her?Please list 5 things you love about your life!Anything else you would like Caitlin to know? Thank you! Congratulations on your commitment to better health. I look forward to serving you. All information is kept strictly confidential. If you have any questions, I encourage you to contact me using the Contact form in the footer of this page after you click Submit. You will be receiving an email from me shortly after you submit your form so please be on the lookout for that. Exciting!! Talk with you soon, CaitlinSubscribe? Please subscribe me to free updates CAPTCHA