Personalized Nutrition Intake Form
  • Date of birth*
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  • Contact Information

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  • Health Information and History

  • If you have a current health condition, or have been diagnosed with one in the past, please list below (eg. diabetes, cancer, IBS etc...)

  • Any history of surgery or hospitalizations?

  • Please indicate if you have had any of the following concerns in the past year, or of significance in the past.

  • Muskuloskeletal
  • Skin
  • Nose and Sinus
  • Mouth and Throat
  • Cardiovascular System
  • Respiratory
  • Neurological
  • Endocrine System
  • Digestive System
  • Urinary System

  • Immune System
  • Mental/Emotional Health

  • Please indicate if any of your family members currently have a health condition, or have had one in the past

     

  • Rows

  • Health Assessment and Medical Information

  • Has your weight ever fluctuated by more than 10lbs in a short period of time?
  • Are you taking any medications? Include any prescription drugs, over-the-counter medication, birth control pill etc..
  • Are you taking any supplements, minerals/vitamins, herbs or other natural health care products?

  • Dietary and Lifestyle Habits

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  • Do you have any known (or suspected) food allergies or intolerances?
  • Do you have any dietary restrictions? (eg. religious, vegan/vegetarian)

  • Please describe a typical day's diet

  • Do you experience any of the following (check all that apply)
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  • Do you consume alcohol?
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  • Do you smoke tobacco?
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  • Are you regularly exposed to second hand smoke?
  • Do you use recreational drugs?

  • Home Environment

  • Do you live close to any of the following?
  • Have you done any recent renovations to your home?
  • Do you have any household pets?

  • Sleep, Energy and Stress Levels

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  • On average, how many hours of sleep do you get?
  • Do you have difficulty falling asleep?
  • Do you have difficulty staying asleep?
  • Do you nap during the day?
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  • Women's Health

    Men please skip to the next page
  • Date of last menstrual period
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  • Rows
  • Are you currently breastfeeding?
  • Are you currently pregnant?
  • Are you trying to become pregnant?
  • Are you currently sexually active?

  • Men's Health

    Women please skip to the next page
  • Are you sexually active?
  • Do you experience painful or difficult urination?

  • Please quickly rate your level of satisfaction with the following areas of your life.

    (1 star = not satisfied, 5 star = very satisfied)

  • Today's Date
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  • Thanks for taking the time to complete this intake form.

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