Nutrition Consultation

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					                              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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posted:12/24/2011
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