Functional Nutrition Guidance

Functional Nutrition Intake Form

Please brew a cup of tea and plan to sit for a moment to complete this form. Because everything is connected.
Full Name

First NameLast Name
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
History
Age
Birthdate
Heritage (check all that apply)

American Indian/Alaska NativeAsianBlackPacific IslanderWhiteLatinXMixed-RaceOtherPrefer not to answer
Principle Language

EnglishSpanishOther (please specify)
Birth weight
Birth order (please list ages of biological siblings)
Gender at birth
Pronouns (she/her, he/him, they/them, other)
Gender Identity

MaleFemaleNon-binaryTransgender female/womanTransgender male/manAnother identityPrefer not to answer
Height
Blood type (if known)
Weight (optional)
Weight one year ago (optional)
Relationship status (check all that apply)

SingleMarried or living with partnerPartnered, not living togetherDivorcedWidowedOther
Partner’s pronouns

She/herHe/himThey/themOther
If you have children, please list their age/ages
Have you or your family recently experienced any major life changes? If so, please comment…
Occupation
Have you traveled outside of the United States? If so, when and where?
Medical Status

Please identify any current or past conditions and add a date for when the condition appeared. In the space below each list, please briefly describe your symptoms, chosen treatment(s), and dates.
Gastrointestinal

Irritable bowel sydromeCrohn’sUlcerative colitisGastritis or Peptic Ulcer DiseaseGERD (reflux or heartburn)Celiac DiseaseSIBOGut InfectionsDysbiosisLeaky gutFood allergies, intolerances or reactionsGallstonesKnown absorption or assimilation issuesOther
For issues check, above, please briefly describe your symptoms, chosen treatment(s) and dates for each.
Cardiovascular

Heart attackHeart diseaseStrokeElevated cholesterolArrhythmia (irregular heartbeat)Hypertension (high blood pressure)Rheumatic feverMitral valve prolapseOther
If any issues check, above, please briefly describe symptoms, chosen treatment(s) and dates:
Hormones/Metabolic

Type 1 DiabetesType 2 DiabetesHypoglycemiaInsulin Resistance or Pre-DiabetesHypothyroidism (low thyroid)Hyperthyroidism (overactive thyroid)Hashimoto’s (autoimmune hypothyroid)Grave’s Disease (autoimmune hyperthyroid)Endocrine ProblemsPolycystic Ovarian Sydrome (PCOS)InfertilityWeight gainWeight lossFrequent weight fluctuationsEating disorderMenopause difficultiesHair lossOther
Please briefly describe your symptoms, chosen treatment(s) and dates for any items check above:
Cancer

Lung cancerBreast cancerColon cancerOvarian cancerProstate cancerSkin cancer (melanoma)Skin cancer (squamous, basal)Other
Please briefly describe your symptoms, chosen treatment(s) and dates:
Genital & Urinary Systems

Kidney StonesGoutFrequent urinary tract infectionsErectile dysfunction or sexual dysfunctionInterstitial cystitisFrequent yeast infectionsOther
Please briefly describe your symptoms, chosen treatment(s) and dates:
Musculoskeletal/Pain

OsteoarthritisFibromyalgiaChronic PainSore muscles or joints, undiagnosedOther
Please briefly describe your symptoms, chosen treatment(s) and dates:
Immune/Inflammatory

Chronic fatigue syndromeRheumatoid arthritisLupus SLERaynaud’sPsoriasisMixed connective tissue disease (MCTD)Poor immune function (frequent infections)Food allergiesEnvironmental allergiesMultiple chemical sensitivitiesLatex allergyHepatitisLyme (and co-infections)Chronic infections (Epstein-Barr, cytomegalovirus, herpes, HPV, STIs, etc.)Other
Please briefly describe your symptoms, chosen treatment(s) and dates:
Respiratory Conditions

AsthmaChronic sinusitisBronchitisEmphysemaPneumoniaSleep apneaFrequent or recurrent colds/fluOthers
Please briefly describe your symptoms, chosen treatment(s) and dates:
Skin conditions

EczemaPsoriasisDermatitisHivesRash, undiagnosedAcneSkin cancer (melanoma)Skin cancer (squamous, basal)Other
Please briefly describe your symptoms, chosen treatment (s) and dates:
Neurologic/Mood

DepressionAnxietyBipolar disorderSchizophreniaHeadachesMigrainesADD/ADHDAutismMild cognitive impairmentMemory problemsParkinson’s diseaseMultiple sclerosisALSSeizuresConcussion/Traumatic brain injuryAlzheimer’sOther
Please briefly describe your symptoms, chosen treatment (s) and dates:
Miscellaneous

AnemiaChicken poxGerman measlesMeaslesMononucleosisMumpsWhooping coughTuberculosisKnown genetic variants (SNPs, polymorphisms, etc)Other
Short term memory impairment
Shortened focus of attention and ability to concentrate
Coordination and balance problems
Problems with lack of inhibition
Poor organization abilities
Problems with time management (late or forget appts)
Mood instability
Difficulty understanding speech and word finding
Brain fog, brain fatigue
Lower effectiveness at work, home or school
Judgement problems like leaving the stone on, etc
Stressful life events

Studies show that past and continued traumas play a significant role in health and health outcomes. Our understanding of your history helps us to best support you through this process and moving forward.
Have you experienced one or more of these stressful life events or traumas in your life? (Check all that apply)

Death of a family member, romantic partner or very close friend because of accident, homicide, or suicideSexual or physical abuse by a family member, romantic partner, stranger, or someone elseEmotional neglect or abuse such as ridicule, bullying, put downs, being ignored or told you were no good by a family member or romantic partnerDiscriminationLife-threatening accident or situation)military combat or living in a war zone)Life-threatening illnessPhysical force or weapon threatened or used against you in a robbery or muggingWitness the murder, serious injury or assault of another person
Is there anything else that you’d like to share about these stressful life events or traumas?
Health concerns
What are your main health concerns? (Describe in detail, including the severity of the symptoms):
When did you first experience these concerns?
How have you dealt with these concerns in the past?

DoctorsSelf-careOther
Have you experienced any success with these approaches? Please explain
What other health practitioners are you currently seeing? List name and specialtyo below.
Please list the date and description of any surgical procedures you have had (including breast reduction or augmentation, gall bladder removal, and any office procedures).
How much time have you had to take off from work to school for health related reasons in the last year? (Add details if you can)
How often did you take antibiotics in infancy/childhood?
How often have you taken antibiotics as a teen?
How often have you taken antibiotics as an adult?
List any medicine you are currently taking:
List all vitamins, minerals, herbs and nutritional supplements you are now taking:
Nutritional Status
Which of the following foods do you consume regularly?

SodaDiet sodaRefined sugarAlcoholGluten (wheat, rye, barley)Fast foodDairy (milk, cheese, yogurt)Coffee
Are you currently on a special diet?

Autoimmune paleo (AIP)SCD/GAPSDairy restricted or dairy- freeVegetarianVeganPaleoBlood typeRawRefined sugar-freeGluten-freeKetogenic dietIntermittent fastingOther (please describe)
What percentage of your meals are home-cooked?

102030405060708090100
Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom:
Do you have symptoms immediately after eating like bloating, gas, sneezing or hives? Do you have any known food allergies or sensitivities? If so, please explain:
Are you aware of any delayed symptoms after eating certain foods such a fatigue, muscles aches, sinus congestion, etc? If so, please explain:
Are there any foods you crave? If so, please explain:
Describe your diet at the onset of your health concerns:
Do you have any known food allergies or sensitivities?
Is there anything else I should know about your current diet, history or relationship to food?
Intestinal Status
Bowel movement frequency

1-3 times per dayMore than 3 times per dayNot regularly every day
Bowel movement consistency

Soft & well formedOften floatDifficult to passDiarrheaThin, long or narrowSmall and hardLoose and wateryAlternating between hard and loose
Bowel movement color

Medium brownVery dark or blackGreenishBlood is visibleVariableYellow, light brownChalky coloredGreasy, shiny
Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc:
Have you ever had food poisoning? If yes, please describe in detail, including 1) where were you 2) what did you treat it with and 3) if you feel like you fully recovered from it:
Potential Health Hazards
To your knowledge, have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)?
Do odors affect you?
Are you or have you been exposed to second-hand smoke?
Are you currently or have you been exposed to mold? (If so, what is/was the source of the exposure and for how long have you been/were you exposed to mold, if known?)
Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?
How long since you last visited the dentist? What was the reason for that visit?
In the past 12 months has a dentist or hygienist talked to you about your oral health, blood sugar or other health concerns? (Explain)
What is your current oral and dental regimen? (Please note whether this regimen is once or twice daily or occasionally and what kind of toothpaste you use.)
Do you have any mercury amalgams? (If no, were they removed? If so, how?)
Have you had any root canals? (If yes, how many and when?)
Do you have any concerns about your oral or dental health? (Gums bleed after flossing, receding gums)
Is there anything else about your current oral or dental health history that you’d like us to know?
Sleep History
Are you satisfied with your sleep?
Do you stay awake all day without dozing?
Are you asleep (or trying to sleep) between 2:00am and 4:00am?
Do you fall asleep in less than 30 minutes?
Do you sleep between 6 and 8 hours per night?
Is there anything else you would like us to know about your sleep?
Reproductive Hormone History

If you do not have female reproductive organs please skip to the next section - Mental Health Status
How old were you when you first got your period?
How are/were you menses? Do/did you have PMS? Painful periods? If so, explain.
In the second half of your cycle do you experience any symptoms of breast tenderness, water retention or irritability?
Have you experienced any yeast infections or urinary tract infections? Are they regular?
Have you/do you still take birth control pills: If so, please list length of time and type.
Have you had any problems with conception or pregnancy?
Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list again here
Mental Health Status
How are your moods in general? Do you experience more anxiety, depression or anger than you would like?
On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy.
At what point in your life did you feel best? Why?
Other
Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain, if no.
Who in your family or on your health care team will be most supportive of you making dietary change?
What role does spirituality play in your life?
Please describe any other information you think would be useful in helping to address your health concern(s):
Should be Empty:

Functional Nutrition Intake Form

History

Medical Status

Stressful life events

Health concerns

Nutritional Status

Intestinal Status

Potential Health Hazards

Sleep History

Reproductive Hormone History

Mental Health Status

Other