Nutritional Assessment Questionnaire

Welcome to Radiant Health
Health and Wellness Assessment Form

Please kindly offer your time to each section so that I can assist you with the best support on your wellness journey.
Full Name:*

First NameLast Name
Phone Number*
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Email*
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Birth Date:*

DayMonthYear
Age:*
Occupation *
Sex:*

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Share your health goals!
What are your main health or wellness goals right now? (e.g., energy levels, weight management, digestive health, Re connect to internal GUT Knowing align with higher Self?) *
Please tell me more about yourself. How is your energy now? If 10 was perfect what range are you in?*
Do you have energy from the a.m. – p.m.? Is there a time in the day when you hit a low?*
How is your sleep?*

I get eight hours of restful sleep!I go to bed with the sun and wake up with the sun.I wake up feeling rested.I wake up multiple times a night.I stay up past 11 o'clock.I only sleep a few hours a night.I sleep eight hours and I'm still tired.I always wake up tired.
Energy Mood & Mood Patterns?

I I crave sweets, and I eat them, and though I get a temporary boost of energy, I later crash!I get irritable, anxious, tired, and jittery, or I get headache, headaches intermittently throughout the day, but feel better temporarily after meals.I have a family, history of diabetes, hypoglycemia.I have a family history of alcoholism.I feel shaky 2 to 3 hours after a meal.I eat low-fat diet, but cannot seem to lose weight.If I miss a meal, I feel cranky and irritable, weak, or tired.If I eat a carbohydrate breakfast(muffin, bagel, cereal, pancakes, etc.) I can't seem to control my eating for the rest of the day.Once I start eating sweets or carbohydrates, I can't seem to stop.If I eat fish or meat and vegetables, I feel good, but seem to get sleepy after eating, a meal, full of pasta, bread, potatoes, and dessert.I go for breakfast at restaurants.I seem salt sensitive. I tend to retain water.I am often moody, and patient, or anxious.I get tired after a few hours after eating.I'm tired most of the time.My memory and concentration are poor.I have extra weight around the middle.I have high blood pressure.
Hydration and Digestive Health

I have fewer than two bowel movements a day.I have undigested food in my stool.I I drink lots of water and I'm still thirsty most of the time.I have normal bowel movements that are banana consistency.My bowel movements are hard like a pebble.Loose stool or diarrhea.
Inflammation Health Assessment

I have seasonal or environmental allergies.I feel poorly after eating (sluggish, headaches, congestion, confusion, phlegm.)I work in an environment with poor lighting, chemicals, and poor ventilation.I get frequent colds or infections.I have a history of chronic infections (skin infections, canker, sores, cold sores.)I have allergies.I have sinus issues.I have arthritis.I have an autoimmune condition(fibromyalgia, rheumatoid arthritis, lupus)
Toxicity/Detoxification Hydration and sweating/ environmental exposure

I drink bottled water.I drink well water.I drink reverse osmosis water.I drink hydrogen water.I get my clothes dry cleaned.I eat large fish (swordfish, tuna, sushi)I use conventional, cleaning or personal care products that may contain harsh chemicals, like bleach, Lysol.
Body Work/ Self Care

I receive acupuncture.I receive bodywork, including massage, or roughing.I receive chiropractic adjustments consistently.I go to yoga a few times a week.I have a home practice.I work out at a gym.I walk weekly.I am an avid hiker.I meditate.I have a spiritual practice.I ride mountain bikes and do extreme sports.
Family Health History

I have a family, history of diabetes.I have a family history of alcoholism.I have had seizures.I have a heart condition and take medication.I have a family history of high LDL, or low HDL cholesterol and high triglycerides.I have a thyroid condition.I have hypothyroid.I have hyperthyroid.
Joint and Muscles

I feel aching or stiffness in my joints.I have muscle aches.I experienced sciatica.
Digestion

I experienced bloating.I sometimes have acid reflux.I have been diagnosed with celiac disease.I have been diagnosed with Crohn's disease.I have experienced gastritis.I take antacids.
Mood and Cognitive Health

I have mood swings.I have difficulty paying attention/brain fog.Memory lossHeadaches..Migraines.I have been on antipsychotic medication.I have been diagnosed with bipolar.I am on anti-anxiety medication.
Woman's Health

Experience PMS.Pre-menopause or menopause symptoms.Irregular menstrual cycle.Experience anger, overwhelm, rage.Thinning hair.
Men's Health

Experience, anger, rage.Frequent urination in the middle of the night.Prostate issues.Prostate cancer or radiation treatmentHair lossI take testosterone shots or pellets.
Allergies and Sensitivities

I have seasonal or environmental allergies.I have allergies and frequently experience sinus issues.I feel sluggish and headaches and congestion, confusion, and phlegm after eating.
Infections and Immune Health

I come down with frequent colds or infections.I have a history of chronic infections.(skin infections, cancer, sores, or cold sores.)
Chronic Inflammatory Conditions

I have arthritis.I have an autoimmune condition fibromyalgiaRheumatoid arthritisLupus.Hashimoto's.I have MS.I have colitis or inflammatory bowel disease.I have irritable bowel syndrome.(spastic colon.)
Dietary Habits

I eat large fish, swordfish, tuna, shark, shellfish.I eat porkI eat dairy more than once or twice a week.I eat chicken.I eat beef.I regularly consume, processed food containing additives or preservatives like MSG or sulfites.I eat out at fast food restaurants like chipotle or Panera.I frequently consume foods and drinks from plastic containers, and our plastic packaging.I consume non-organic produce that may have pesticides and glyphosate.
Do you experience energy crashes during the day? If so, when? Do you drink energy drinks to give you more energy, if so what kind. *
Radiant Health Assessment

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Do you drink coffee? If yes, how many times a day do you usually have it, and at what times? What brand?*
Do you add sugar and creamer? If so, how much? Do you use Oatly Milk?*
Can you describe a typical day of meals and snacks for you? How much water? Do you drink soda? Do you drink alcohol of any kind? And how often and how much?
Are there any foods you eat regularly or avoid?
Are you currently experiencing any chronic pain or joint pain? If yes, can you describe the pain (location, severity, frequency)? *
What kind of toothpaste, deodorant, household, cleaners, do you use?
Have you ever done a parasite cleanse? What brand?
Please do share if you've done any cleansing in the past.
Radiant Health Assessment
Dental Health

I have more than one or two mercury an album fillings.Other
Medication and supplements

I regularly consume the following substances or medications: Tagamet, Zantac, Pepcid, Prilosec, ibuprofen, or acetaminophen.Other
Do you have any medical conditions or chronic illness that affect your health like diabetes, heart disease, thyroid issues please explain.
Have you experienced any significant health events in the past (e.g., surgeries, hospitalization, or injuries
Are you currently taking any prescription medication's or over-the-counter drugs? Any anti-depressants are you taking any blood thinners or medication for chronic conditions? Please explain.
Do you take any vitamins, minerals, or other supplements regularly? *
Please list the names of all natural supplements you are currently taking and for what conditions *
Do you have any medical conditions or chronic illnesses that affect your health (e.g, diabetes, heart disease, thyroid issues)? *
Social History
How many alcoholic beverages do you consume per week?
How many times do you eat out per day?
Per week?
How many caffeinated beverages do you consume per day?
How many times a week do you eat fish?
How many times a week do you eat raw nuts or seeds?
Do you smoke?
If yes, how many times per day?
How many times per week do you workout?
Motivation & Health Journey:
Have you tried any approaches to improve your health before, and if so, what were the outcome? *
Food Preferences & Lifestyle:
Are you following any specific eating pattern? (e.g., plant-based, low-carb, intermittent fasting) *
Do you have any nutritional preferences or restrictions (e.g., vegan, gluten-free, etc.)? *
Exercise and Activity LevelSelf-Care Practices
What's your usual exercise routine, if any, how often do you find time each day or week? *
How do you prioritize self-care practices in your daily routine? And Do you want support?*
Hydration:
How much water do you typically drink in a day?

I start the day with waterI drink coffee before I drink waterI want to upgrade my waterOther
Do you consume other beverages, like tea, energy drinks, sugary drinks, juices? *
Sleep & Stress:
How many hours of sleep do you usually get each night? Please describe your sleep pattern in detail. What time do you typically go to bed, and when do you wake up? Do you wake up during the night? If so, how many times, and around what hours? Do you feel rested when you wake up in the morning? *
How would you rate your stress levels on a typical day ( on a scale from 1-10, 10 being the highest)? *
Challenges:
What's the biggest challenge you face when it comes to achieving your health goals or sticking to a balanced routine? *
Please list all medications you are currently taking and for what conditions?
How important is it to you to take your healing into your own hands and take full responsibility for the healing of your own body? How important is it to achieve radiant health and to hit your goal?
Do you Have Any Reports / Scanned Reports ?

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Welcome to Radiant Health

Health and Wellness Assessment Form

Radiant Health Is on it's way!

Radiant Health Assessment

Radiant Health Assessment

Social History

Motivation & Health Journey:

Food Preferences & Lifestyle:

Exercise and Activity LevelSelf-Care Practices

Hydration:

Sleep & Stress:

Challenges: