Trudy Scott

Initial Assessment

Trudy Scott, CN (Certified Nutritionist) | Cell (916) 6056283 or trudy@everywomanover29.com
Full Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
E-mail*
Birth Date

MonthDayYear
Current Weight
Ideal Weight
Height
Blood Pressure
Gender

MaleFemale
Age
Marital status
Able to work full-time?

YesNo
Profession
Past profession(s)
Do you have a medical diagnosis? If yes, what?
Referred by or How did you find me?
Please list your top 5 health goals.
Your Mood/Energy/Sleep/Digestion – please rate how bad and add notes if needed.

Depressed?

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1 is Best, 10 is Worst

...additional notes on "Depressed?"

Suicidal now/past/thoughts?

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1 is Best, 10 is Worst

...additional notes on "Suicidal now/past/thoughts?"

Mood swings? Daily? Monthly? Other?

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1 is Best, 10 is Worst

...additional notes on "Mood swings? Daily? Monthly? Other?"

Anxiety?

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1 is Best, 10 is Worst

...additional notes on "Anxiety?"

Panic attacks?

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1 is Best, 10 is Worst

...additional notes on "Panic attacks?"

Inability to socialize?

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...additional notes on "Inability to socialize?"

Low energy? Focus?

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1 is Best, 10 is Worst

...additional notes on "Low energy? Focus?"

Poor sleep? Number of hrs?

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1 is Best, 10 is Worst

...additional notes on "Poor sleep? Number of hrs?"

Poor digestion?

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1 is Best, 10 is Worst

...additional notes on "Poor digestion?"

Stressed out in general?

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...additional notes on "Stressed out in general?"

Obsessive behaviors or thoughts?

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...additional notes on "Obsessive behaviors or thoughts?"

Hormonal issues? PMS? Menopause?

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...additional notes on "Hormonal issues? PMS? Menopause?"

Thyroid issues?

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...additional notes on "Thyroid issues?"

Other mood issues?

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...additional notes on "Other mood issues?"

Depressed?

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1 is Best, 10 is Worst

...additional notes on "Depressed?"
Your Work Stress – please rate how bad and add notes if needed.

Work overwhelm?

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1 is Best, 10 is Worst

...additional notes on "Work overwhelm?"

Work worry & fear about decisions?

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...additional notes on "Work worry & fear about decisions?"

Procrastination?

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1 is Best, 10 is Worst

...additional notes on "Procrastination?"

Negative self-talk and/or inner dialogue? Critic on the shoulder?

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1 is Best, 10 is Worst

...additional notes on "Negative self-talk and/or inner dialogue? Critic on the shoulder?"

Perfectionist? No one can do it as well as me?

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...additional notes on "Perfectionist? No one can do it as well as me?"

“I am a fraud”/imposter syndrome?

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...additional notes on "“I am a fraud”/imposter syndrome?"

Do you consider yourself an introvert?

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...additional notes on "Do you consider yourself an introvert?"

Workaholic? Working long hours? Hours per week?

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...additional notes on "Workaholic? Working long hours? Hours per week?"

Use coffee and/or sugar to keep going?

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...additional notes on "Use coffee and/or sugar to keep going?"

Emotional and crying spells?

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1 is Best, 10 is Worst

...additional notes on "Emotional and crying spells?"

Feel better when exercising?

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...additional notes on "Feel better when exercising?"
Your Food/Eating/Drugs/Alcohol – please rate how bad and add notes if needed.

Cravings? What do you crave? When?

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1 is Best, 10 is Worst

...additional notes on "Cravings? What do you crave? When?"

Calorie restriction/calorie counting/dieting?

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...additional notes on "Calorie restriction/calorie counting/dieting?"

Binging? Purging? How often? For how long?

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1 is Best, 10 is Worst

...additional notes on "Binging? Purging? How often? For how long?"

Use of alcohol/drugs? Addiction? What? How much? And how often?

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1 is Best, 10 is Worst

...additional notes on "Use of alcohol/drugs? Addiction? What? How much? And how often?"

Eat sugar or drink alcohol to calm down?

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1 is Best, 10 is Worst

...additional notes on "Eat sugar or drink alcohol to calm down?"
Vegetarian? For how long? Would you consider adding any animal products into your diet?
Anything else I should know about your eating habits?
Your Medications now (name, dose, reason taking)
Your Medications in the recent past (name, dose, reason taking, response/reaction)
Your Supplements now (name, dose, reason taking)
Have you used targeted individual amino acids (glutamine, GABA, tryptophan, 5-HTP, DPA or tyrosine) and had good results with anxiety mood, cravings, fatigue?
Have you tried any other supplements and/or other natural methods and had good results with anxiety mood, cravings, fatigue?
Are you in therapy/12-step etc now (or in the past)? Please elaborate.
Your family – mood, addictions, eating disorders and other conditions
Depressed

Grandparent/sParent/sBrother, sisterChildOther blood relative
Anxious

Grandparent/sParent/sBrother, sisterChildOther blood relative
Food Addiction/ Eating disorder

Grandparent/sParent/sBrother, sisterChildOther blood relative
Alcohol/Drug Abuse

Grandparent/sParent/sBrother, sisterChildOther blood relative
Thyroid problems

Grandparent/sParent/sBrother, sisterChildOther blood relative
Heart disease/stroke

Grandparent/sParent/sBrother, sisterChildOther blood relative
Cancer

Grandparent/sParent/sBrother, sisterChildOther blood relative
Fertility/miscarriage

Grandparent/sParent/sBrother, sisterChildOther blood relative
Other health conditions in family members
Anything else I should know about?
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Initial Assessment