Nutrition EvaluationKORU PHARMACY
Name
Email
example@example.com
Phone #
Format: (000) 000-0000.
Birthdate
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Height
Weight
Desired Weight
Age
Sex
Reason for Visit / Health Goals
Expectations for Visit
Were you born vaginally?
Yes
No
How many months did your mother breast feed you?
Please Select
Never
less than 3 months
3-6 months
6-12 months
12 months or more
Are the following food preferences / practices a priority for you?
Rows
Absent
Mild
Moderate
Severe
Organic
Grass fed beef
Wild caught fish
Non-Gmo
Gluten free
Dairy free
Whole foods
Avoid processed foods
Avoid artificial sweeteners
Avoid synthetic ingredients
Avoid food colors
Avoid fast food
Vegetarian
Vegan
Fasting
Ketogenic diet
SLEEP & OTHER HEALTH: Do you?
Rows
No
Yes
Have trouble falling asleep?
Trouble staying asleep?
Wake up feeling rested and ready for the day?
Have a mid afternoon slump?
Avoid blue light at least one hour before bed?
Avoid alcohol at least two hours before bed?
Avoid eating at least two hours before bed?
Fall asleep at approximately the same time each night?
Wake at approximately the same time each morning?
Make prayer or meditation a regular part of your day?
Make exercise a priority every day?
Strength train at least 2 times per week?
Exercise 3-5 times per week?
Take infrared sauna therapy currently or in the past?
Take red light therapy currently or in the past?
Take cold showers or cold plunges?
How many ounces of water do you typically consume daily?
How much caffeine do you drink on a daily basis?
Please Select
Occasionally
Once a day
Twice a day
More than twice a day
How often do you consume alcohol?
Please Select
Never
Once a month or less
Once a week or less
1 -2 times weekly
More than 2 times weekly
DIGESTIVE CHECKLIST
Rows
Never
Mild
Moderate
Severe
Constipation
Diarrhea
Reflux
Gas
Bloating
Stomach pains
Never feel satisfied
Never feel hungry
Food cravings
Tired after eating
Eating too fast
Nausea
MENTAL / MOOD CHECKLIST
Rows
Never
Mild
Moderate
Severe
Anxiety
Stress
Depressed
Feelings of sadness
Lack of motivation
Brain fog
Poor memory
Insomnia
Trouble falling asleep
Feelings of calmness / relaxation
Irritable
HORMONAL CHECKLIST
Rows
Never
Mild
Moderate
Severe
Hot flashes
Night sweats
Weight gain (waist)
Mood swings
Fatigue
Brain fog
Salt cravings
Sugar cravings
Decreased muscle mass
Weight loss resistance
TOXICITY CHECKLIST
Rows
Never
Mild
Moderate
Severe
Fatigue
Headaches
Dizziness
Mood swings
Fatigue
Brain fog
Salt cravings
Sugar cravings
Decreased muscle mass
Weight loss resistance
Do you have a history of:
Rows
No
Yes
Allergies
Asthma
Eczema
Psoriasis
Arthritis
Auto-immune condition (s)
Antibiotic use
Mold exposure
Heavy metal exposure
Current medical health provider:
Do you have any medical conditions? If yes please specify:
Please list all current prescriptions & indication:
Please list all current supplements & indication:
What do you eat in a day? Please provide one or two typical days of nutrition for you including time of day, food and quantity. Be as specific as possible.
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