VIEWS: 27 PAGES: 3 POSTED ON: 12/24/2011
Nutrition Consultation Name: ____________________________ Date: ___________________ Referred By: ___________________ Birth Date: _____________ Gender: _________ Please list your primary health concerns/reason for visit: ________________________________________________________________________ ________________________________________________________________________ Goals you hope to achieve: _________________________________________________ What is your current weight?________________ Ideal weight?____________________ HEALTH HISTORY Please list any medical problems that you have been diagnosed with: ________________________________________________________________________ ________________________________________________________________________ Please list any prescribed drugs or over-the-counter medication you are currently taking: ________________________________________________________________________ ________________________________________________________________________ Please list any vitamins, minerals, herbal or other remedies you are currently taking: ________________________________________________________________________ ________________________________________________________________________ Please list any allergies or sensitivities: ________________________________________________________________________ How often do you have a bowel movement? (EG: # per day) _______________________ Do you strain to have a bowel movement? Yes No Occasionally Related to any particular food or circumstances?_________________________________ Do you have loose bowel movements? Yes No Occasionally Related to any particular food or circumstances?_________________________________ Do you smoke?________ If yes, how much and for how long? __________________ Does anyone in your household or workplace smoke? __________________ Have you ever been treated for drug and/or alcohol dependency? __________________ Do you have any silver-mercury fillings? ________________________ How would you rate your present energy level (1-10, 10 being highest)? ____________ Exercise: Sedentary (No exercise) Mild Exercise (ie stairs, walk 3 blocks, golf) Occasional Vigorous Exercise (work or recreation less than 4x/week for 30min) Regular Vigorous Exercise (work or recreation 4x/week for 30min) List Activities: ________________________________________________________________________ How would you rate your present stress levels (1-10, 10 being highest)? _____________ What are the major causes of your stress? _____________________________________ ________________________________________________________________________ How does your stress manifest itself? ________________________________________________________________________ How many hours do you sleep daily (including naps)? ____________________________ What time do you go to sleep? _________________ Wake up? ____________________ Do you awake feeling rested? _______________________________________________ FAMILY HISTORY _______Heart Disease _______Mental Illness _______Hypertension _______Intestinal Disease _______Diabetes _______Ulcers _______Allergies _______Gall Bladder Problems _______Arthritis _______Kidney Problems _______Osteoporosis _______Asthma _______Alcoholism _______Cancer, type:_______________ FEMALES Are you or could you be pregnant?____________________________________________ Are you trying for pregnancy? Y ___ N ___ Do you experience any of the following: Heavy Periods Irregular Periods PMS Are you pre-menopausal or menopausal?_______________________________________ Are you experiencing any menopausal symptoms?_______________________________ If yes, please specify:______________________________________________________ DIETARY HABITS How many times a day do you eat: Main Meals___________ Times of day:_______________________________________ Snacks_______________ Times of day:_______________________________________ Do you have diet restrictions due to preferences of others (family/roommate) _________ If yes, explain:_________________________________________________ How many ½ cup servings of each do you typically eat in a day: Fruit:________Fresh________Dried________Canned Vegetables:_________Cooked___________Raw Whole Grains:__________ Protein:_________Type:____________________________________________________ Dairy:__________Type:____________________________________________________ Other: __________________________________________________________________ Please list examples of your typical meals: Breakfast:_______________________________________________________________ Lunch:__________________________________________________________________ Dinner:_________________________________________________________________ Snacks:_________________________________________________________________ Do you use/eat the following: (“0” = never, “1” = rarely, “2” = sometimes, “3” = often) ____Aluminum Pans ____Margarine ____Candy ____Microwave ____Fried Foods ____Refined Foods ____Aspartame/Splenda ____Fast Foods ____Luncheon Meats Please indicate the number of cups of the following you drink per day: ____tap water ____alcoholic drinks ____diet soft drinks ____bottled/spring water ____tea ____soft drinks ____milk ____herbal tea ____juice ____coffee other: ________________________________________________ Do you avoid any foods? Explain:____________________________________________ ________________________________________________________________________ Do you experience any symptoms if meals are missed? Explain:____________________ ________________________________________________________________________ Do you experience any symptoms after meals? Explain:__________________________ ________________________________________________________________________ OTHER COMMENTS ________________________________________________________________________ ________________________________________________________________________ CLIENT STATEMENT I hereby attest to the following: 1. That I am here, on this and any subsequent visit, solely on my own behalf and not as an agent for any federal, provincial, municipal or professional agency on a mission of entrapment or investigation. 2. I fully understand that Dr. Michael Schmolke is not a medical doctor and that any diagnostic or treatment procedures are given to the best of his abilities within his scope of practice and his experience in clinical nutrition, nutriceuticals, homeopathics, and complementary medical treatments. With this understanding, some conditions and circumstances will still require collaborative work with your medical physician, and/or more advanced testing to confirm diagnosis, guide treatment recommendations, and assess success of any outcomes of a therapeutic nature. 3. This agreement is being signed voluntarily and not under duress of any kind. Name:____________________________________ Date:_________________________ Signature:_______________________________________________________________ Address:________________________________________________________________ City:_______________________Province:______________Postal Code:_____________ Phone:__________________________________________________________________ Thank-you for your cooperation. All information contained in this form will be kept strictly confidential.
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