Nutrition and Medical History Questionnaire Name Email 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Best Daytime PhoneAlternative PhoneDate of Birth MM slash DD slash YYYY Marital StatusSingleMarriedDivorcedWidowedDatingSignificant otherOccupation If applicable, number of children & age(s)Referred By Medical History List any medical diagnosisList medications, vitamins & herbal preparationsDo you currently take a probiotic? Yes No If 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 HistoryHeight 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 ClientsPlease tell me why you want to lose weightList Latest Lab Values, If Available and DateIron 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 HabitsFrequency 1 – 3 X Day More Than 3 X Day Not Regularly Everyday Do you experience excessive intestinal gas? Yes No Exercise HistoryDo 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 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? 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 InventoryFood 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 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? Yes No Types Weekly Amount Do You Drink Coffee/Tea? Yes No Regular Or Decaf? Daily Amount Other Beverages? Daily Amount Food 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)? 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 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 Δ