Caitlin Russell Nutrition | Weight Loss | LEAP Food Sensitivity Testing

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Nutrition and Medical History Questionnaire

Name
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Best Daytime Phone
Alternative Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Marital Status
Occupation
If applicable, number of children & age(s)
Referred By
Medical History
List any medical diagnosis
List medications, vitamins & herbal preparations
Do you currently take a probiotic?
- Yes
- No
If yes above, what is your probiotic and when do you take it?
Challenges
What 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 History
Height
Current Weight
Desired Weight
Lowest Weight In Past Year
Highest Weight In Past Year
Do You Want To Lose/Gain/Maintain Weight?
If Applicable, When (And How) Did Your Weight Gain Or Weight Loss Begin?
For Weight Loss Clients
Please tell me why you want to lose weight
List Latest Lab Values, If Available and Date
Iron
TIBC
Ferritin
Transferrin
B12
Glucose
Total cholesterol
LDL cholesterol
HDL cholesterol
Triglycerides
AST
ALT
Vitamin D
Thyroid TSH
Total T4
T3 Uptake
T4 Free
Anti-Thyroglobulin AB
Progesterone
Testosterone total
Homocysteine
Insulin Like Growth Factor (IGF)
C-Peptide
Leptin
Hb-A1c
Celiac Test Results
Bowel Habits
Frequency
- 1 – 3 X Day
- More Than 3 X Day
- Not Regularly Everyday
Do you experience excessive intestinal gas?
- Yes
- No
Exercise History
Do you exercise?
If no, why?
Type of exercise
How often?
For how long?
Describe other physical activities
What kinds of circumstances interfere with physical activity?
Choose the best description of your energy level
- Usually energetic/occasionally tired
- Average energy/sometimes more energetic/sometimes more tired
- Frequently tired/occasionally energetic
- Always tired/no energy
Sleep & Stress Habits
What 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?
- Yes
- No
Do you use your phone/computer/watch TV right before bed?
- Yes
- No
Do you currently practice yoga?
- Yes
- No
If yes above, how often?
Do you currently practice meditation?
- Yes
- No
If yes above, how often?
How do you cope with stress in your life?
Food Choice Inventory
Food Dislikes
Food Allergies/Intolerances
Do you currently eat a gluten-free diet?
- Yes
- No
If yes above, how would you classify your gluten-free diet?
- 100% gluten-free
- Mostly gluten-free but some gluten foods occasionally
Do you currently consume dairy?
- Yes
- No
If yes above, what type(s) of dairy?
- milk
- cheese
- yogurt
- cottage cheese
- ice cream
- other
Meal Planning
How Many People In Your Household?
Who Plans Meals?
Who Cooks?
Who Shops?
Is A Shopping List Used?
Dining Out
How Often Do You Eat Out Each Week?
What Meals?
Where?
How Many Times Each Week Do You Eat At A Fast Food Restaurant?
Where?
Beverages
Do You Drink Alcohol?
- Yes
- No
Types
Weekly Amount
Do You Drink Coffee/Tea?
- Yes
- No
Regular Or Decaf?
Daily Amount
Other Beverages?
Daily Amount
Food Habits
Do 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)?
- Yes
- No
If you practice IF, what form?
- 12:12
- 16:8
- 18:6
- 5:2
- 24 hour or 36 hour
- Longer or other pattern
Are you interested in learning more about IF?
- Yes
- No
- Unsure/Maybe
What Is Your Current Diet Like? List What You Generally Eat For:
Breakfast
Lunch
Dinner
Snacks
Beverages
Also, List Approximate Times You Eat:
Breakfast
Lunch
Dinner
Snacks
Do 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 History
Do 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,
Caitlin
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I’ve found an approach to food and body that is life changing.

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About Caitlin

I help clients create a healthier relationship with food, which creates a more balanced life. I enjoy helping clients overcome struggles with weight (as I myself discovered what works best for my health and well-being.)

There is no pill. There is no magic supplement. But there is a way. Let me help you find your way, so you too can experience life as it is meant to be – free from worry over weight, free from diets, free to love yourself.

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