Happy Apple Nutrition Intake Forms

Diet Total
2 - Upper GI Total
3 - Liver and Gallbladder Total
4 - Small Intestine Total
5 - Large Intestine Total
6 - Mineral Needs Total
7 - Fatty Acids Total
8 - Sugar handling Total
9 - Vitamin Need Total
10 - Adrenal Total
11 - Pituitary Total
12 - Thyroid Total
13 - Cardiovascular Total
14 - Kidney/Bladder Total
15 - Immune Total
Female Only Total
Male Only Total
Intake Interview Form and Nutritional Assessment Questionnaire
Date

MonthDayYear
Date
Name

First NameLast Initial
Email
example@example.com
Referred by:

HAPPY APPLE NUTRITION

Syrah McGivern

Registered Dietitian, Licensed Dietitian Nutritionist

This is a generic Functional Nutrition Questionaire.

The point of fillling out this questionaire is to get information about nutritional foundations affecting your health:

- Digestion
- Blood Sugar Regulation
- Fatty Acid Balance
- Mineral Balance
- Hydration

I will use this information to help assess your nutritional needs and make recommendations for nutrition changes and nutritional supplements to support your specific nutritional needs and goals.

I am committed to protecting client privacy.

I take all reasonable steps to protect your Information from unauthorized access, use, or disclosure by using strong passwords, up-to-date software on all devices, and locking file cabinets for physical documents. However, even the best security practices cannot guarantee that all stored data will be completely free from third-party interception or corruption.

In accordance with Standards for Privacy of Individually Identifiable Health Information, your consent is required for me to collect, use, and disclose your personal Information. By signing below, you acknowledge your consent for me to collect your Information.

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By signing below, I confirm that I have read and fully understand the above disclaimer, am in complete agreement thereto, and do freely without duress sign and consent to all terms contained herein:
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Date of Birth

MonthDayYear
Date
Gender

MaleFemalePrefer not to say
Age
Height
Weight
Occupation
On average, how many hours do you work per week?
Relationship Status
Number of Children
Blood Type (if known)
Hobbies/Activities
What are your top 3-5 health concerns?
What would you like to gain from working together? What are your personal health goals?

	Never	Monthly	Weekly	Daily
Drink Alcohol
Artificial Sweeteners
Candy, desserts, refined sugar
Carbonated beverages, including sparkling water
Chewing tobacco
Cigarettes
Cigars/Pipes
Caffeinated Beverages
Fast Foods
Fried Foods
Luncheon Meats
Margarine
Dairy products
Radiation exposure
Refined flour/Baked goods
Vitamins and Mineral Supplements
Distilled Water
Tap Water
Well Water
Diet for weight control

	Never	Monthly	Weekly	Daily
Belching or gas within one hour after eating
Heartburn or acid reflux
Bloating within one hour after eating
Vegan diet (No=Never, Yes=Monthly)
Bad Breath
Loss of taste for meat
Sweat has a strong odor
Stomach gets upset from taking vitamins
Sense of excess fullness after meals
Feel like skipping breakfast
Feel better if you don't eat
Sleepy after meals
Fingernails chip, peel, or break easily
Anemia unresponsive to iron
Stomach pains or cramps
Diarrhea, chronic
Diarrhea shortly after meals
Black or tarry colored stools
Undigested food in stool

	Never or NO	Monthly or YES	Weekly	Daily
Pain between shoulder blades
Stomach upset by greasy foods
Greasy or shiny stools
Nausea
Sea, car, or airplane motion sickness
Light or clay colored stools
Dry skin, itchy feet, or skin peels on feet
Headache over eyes
Gallbladder attacks
History of morning sickness
Bitter taste in mouth, especially after meals
Alcoholic drinks per week (none, 1-3, 4-7, or 7+)
Exposure to diesel fumes
Pain under right side of rib cage
Nutrasweet or Aspartame consumption (typically in diet drinks, diet products)
Chronic fatigue or Fibromyalgia
Gallbladder removed
Become sick if you were to drink wine
Easily intoxicated if you were to drink wine
Easily hungover if you were to drink wine
Recovering Alcoholic
History or drug or alcohol abuse
History of hepatitis
Long term use of prescription or recreational drugs
Sensitive to chemicals (perfume, cleaning agents, etc)
Sensitive to tobacco smoke
Hemorrhoids or varicose veins

	Never or NO	Monthly or YES	Weekly	Daily
Food allergies
Abdominal bloating 1-2 hours after eating
Specific foods make you tired or bloated
Pulse speeds after eating
Airborne allergies
Experience hives
Sinus congestion/stuffy head
Crave bread or noodles
Alternating constipation and diarrhea
Crohn's disease (No,Yes)
Wheat or grain sensitivity
Dairy sensitivity
Are there foods you could not give up? (No,Yes)
Asthma, sinus infections, stuffy nose
Bizarre, vivid dreams, nightmares
Use over-the-counter pain medications
Feel spacey or unreal

	Never or NO	Monthly or YES	Weekly	Daily
Anus itches
Coated tongue
Feel worse in moldy or musty place
Taken antibiotics for a total accumulated time of(Never taken antibiotics, Less than 1 month, 1-2 months, 3+ months)
Fungus or yeast infections
Ring worm, "jock itch", "athletes foot", nail fungus
Yeast symptoms increase with sugar,starch or alcohol (Yeast symptoms include: fatigue, poor memory, feeling'spacey' or 'unreal', muscle aches or weakness, pain or swelling in joints, constipation, diarrhea or bloating.
Stools hard or difficult to pass
History of parasites
Less than one bowel movement per day
Stools have corners or edges, are flat, or ribbon shapped
Stools are not well formed (loose)
Irritable bowel or mucus colitis
Blood in stool
Mucus in stool
Excessive foul smelling lower bowel gas
Bad breath or strong body odors
Painful to press along the outer sides of the thighs
Cramping in lower abdominal region
Dark circles under eyes

	Never or NO	Monthly or YES	Weekly	Daily
History of carpal tunnel syndrome
History of lower right abdominal pains or ileocecal valve problems
History of stress fracture
Bone loss (reduced density on bone scan)
Are you shorter than you used to be?
Calf, foot, or toe cramps at rest
Cold sores, fever blisters, or herpes lesions
Frequent fevers
Frequent skin rashes and/or hives
Herniated disc
Excessively flexible joints, "double jointed"
Joints pop or click
Pain or swelling in joints
Bursitis or tendonitis
History of bone spurs
Morning stiffness
Nausea with vomiting
Crave chocolate
Feet have a strong odor
History of anemia
Whites of eyes are blue tinted
Hoarseness in voice
Difficulty swallowing
Lump in throat
Dry mouth, eyes, and/or nose
Gag easily
White spots on fingernails
Cuts heal slowly and/or scar easily
Decreased sense of taste or smell

	Never or NO	Monthly or YES	Weekly	Daily
Experience pain relief with aspirin
Crave fatty or greasy foods
Low or reduced-fat diet
Tension headaches at base of skull
Headaches when out in the hot sun
Sunburn easily or suffer sun poisoning
Muscles easily fatigued
Dry flaky skin or dandruff

	Never or NO	Monthly or YES	Weekly	Daily
Awaken a few hours after falling asleep, hard to get back to sleep
Crave sweets
Binge or uncontrolled eating
Excessive appetite
Crave coffee or sugar in the afternoon
Sleepy in the afternoon
Fatigue that is relieved by eating
Headache if meals are skipped or delayed
Irritable before meals
Shaky if meals delayed
Family members with diabetes
Frequent thirst
Frequent urination

	Never or NO	Monthly or YES	Weekly	Daily
Muscles easily become fatigued
Feel exhausted or sore after moderate exercise
Vulnerable to insect bites
Loss of muscle tone, heaviness in arms/legs
Enlarged heart or congestive heart failure
Pulse below 65 per minute
Ringing in the ears
Numbness, tingling, or itching in hands and feet
Depressed
Fear of impending doom
Worrier, apprehensive, anxious
Nervous or agitated
Feelings of insecurity
Heart races
Can hear heart beat on pillow at night
Whole body or limb jerk as falling asleep
Night sweats
Restless leg syndrome
Cracks at corner of mouth
Fragile skin, easily chaffed, as in shaving
Polyps or warts
MSG sensitivity
Wake up without remembering dreams
Small bumps on back of arms
Strong light at night irritates eyes
Nose bleeds and/or tend to bruise easily
Bleeding gums especially when brushing teeth

	Never or NO	Monthly or YES	Weekly	Daily
Tend to be a "night" person
Difficulty falling asleep
Slow starter in the morning
Tend to be keyed up, trouble calming down
Blood pressure above 120/80
Headache after exercising
Feeling wired or jittery after drinking coffee
Clench or grind teeth
Calm on the outside, troubled on the inside
Chronic low back pain, worse with fatigue
Become dizzy when standing up suddenly
Difficulty maintaining manipulative correction
Pain after manipulative correction
Arthritic tendencies
Crave salty food
Salt foods before tasting
Perspire easily
Chronic fatigue, or get drowsy often
Afternoon yawning
Afternoon headache
Asthma, wheezing, or difficulty breathing
Pain on the medial or inner side of the knee
Tendency to sprain ankles or "shin splints"
Tendency to need sunglasses
Allergies and/or hives
Weakness, dizziness

	Never or NO	Monthly or YES	Weekly	Daily
Height over 6'6"
Early sexual development, before age 10
Increased libido
Splitting type headaches
Memory failing
Tolerate sugar, feel fine when eating sugar
Height under 4'10"
Decreased libido
Excessive thirst
Weight gain around hips or waist
Menstrual disorders
Delayed sexual development (after age 13)
Tendency to ulcers or colitis

	Never or NO	Monthly or YES	Weekly	Daily
Sensitive/allergic to iodine
Difficulty gaining weight, even with large appetite
Nervous, emotional, can't work under pressure
Inward trembling
Flush easily
Fast pulse at rest
Intolerance to high temperatures
Difficulty losing weight
Mentally sluggish, reduced initiative
Easily fatigued, sleeping during the day
Sensitive to cold, poor circulation (cold hands and feet)
Constipation, chronic
Excessive hair loss and/or coarse hair
Morning headaches, wear off during the day
Loss of lateral 1/3 of eyebrow
Seasonal sadness

	Never or NO	Monthly or YES	Weekly	Daily
Aware of heavy and/or irregular breathing
Discomfort at high altitudes
Air hunger or sigh frequently
Compelled to open windows in a closed room
Shortness of breath with moderate exertion
Ankles swell, especially at end of day
Cough at night
Blush or face turns red for no reason
Dull pain or tightness in chest and/or radiate into right arm, worse with exertion
Muscle cramps with exertion

	Never or NO	Monthly or YES	Weekly	Daily
Pain in mid-back region
Puffy around the eyes, dark circles under eyes
History of kidney stones
Cloudy, bloody, or darkened urine
Urine has a strong odor

	Never or NO	Monthly or YES	Weekly	Daily
Runny or drippy nose
Catch colds at the beginning of winter
Mucus producing cough
Frequent colds or flu
Other infections (sinus, ear, lung, skin, bladder, kidney, etc)
Never get sick
Acne (adult)
Itchy skin (dermatitis)
Cysts, boils, rashes
History of Epstein-barr, Mono, Herpes, Shingles, Chronic Fatigue Syndrome, Hepatitis, or other chronic viral condition

	Never or NO	Monthly or YES	Weekly	Daily
Depression during periods
Mood swings associated with periods (PMS)
Crave chocolate around periods
Breast tenderness associated with cycle
Excessive menstrual flow
Scanty blood flow during periods
Occasional skipped periods
Variations in menstrual cycle length
Endometriosis
Uterine fibroids
Breast fibroids, benign masses
Painful intercourse
Vaginal discharge
Vaginal dryness
Vaginal itchiness
Tendency to gain weight around hips, thighs, and buttocks as opposed to other areas such as the mid-section
Excess facial or body hair
Hot flashes
Night sweats (in menopausal females)
Thinning skin

	Never or NO	Monthly or YES	Weekly	Daily
Prostate problems
Difficulty with urination, dribbling
Difficult to start and stop urine stream
Pain or burning with urination
Waking to urinate at night
Interruption of stream during urination
Pain on inside of legs or heels
Feeling of incomplete bowel evacuation
Decreased sexual function

Intake Interview Form and Nutritional Assessment Questionnaire