Nutrition & 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

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?

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:

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

Subscribe?