Holistic Nutritional Assessment - Kathleen Groves, RHN
Full Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
E-mail
Age
Gender
Female
Male
Height
Weight
What are your health goals or concerns?
Do you have any medical conditions?
Yes
No
If Yes - Please outline here
Are you currently taking any medication?
Yes
No
If Yes - what for?
Do you take any supplements?
Yes
No
If Yes - what for?
Do you have any allergies or sensitivities?
Yes
No
If yes, please list
Are there any medical conditions or diseases that run in your family?
On a scale of 1(low) to 10(high) rate your current level of stress
1
2
3
4
5
6
7
8
9
10
What contributes to your stress? (Check all that apply)
Financial
Career
Personal
Marriage
Health
Family
Spiritual
Anxiety
Unfulfilled Expectations
What is your occupation?
Do you work shifts?
Yes
No
Do you currently exercise?
Yes
No
If yes, how often on average per week?
What kind of exercise?
On a scale of 1(low) to 10(high) rate your over all energy levels ?
1
2
3
4
5
6
7
8
9
10
Do you have any highs or lows in your energy throughout the day?
Yes
No
If Yes, when?
How many hours per day do you sleep?
What time do you go to bed?
What time do you wake?
Do you have trouble falling asleep?
Yes
No
Do you have trouble staying asleep?
Yes
No
How often do you have a bowel movement?
Are you ever constipated?
Yes
No
If Yes, is it related to a certain food? If so which food.
Do you ever have loose stools or see any foods in your stool?
Yes
No
If Yes, is it related to any certain food? If so which food.
Are you ever crampy or bloated after eating?
Yes
No
Do you know what it is related to?
For Women:
Are or could you be pregnant or breast feeding?
Yes
No
Have there been any changes lately in your period?
Yes
No
If yes, please specify.
Do you have PMS?
Yes
No
Are you pre-menopausal?
Yes
No
Are you post-menopausal?
Yes
No
Are you experiencing menopausal symptoms ?
Yes
No
if yes, please specify.
For Men:
Do you have prostate problems (frequent urination, or discomfort during urination)?
Yes
No
Have you experienced a decline in sexual interest?
Yes
No
Food:
Do you eat dessert?
How many snacks a day do you eat?
How many meals a day do you eat?
What are some examples of your typical:
Breakfast
Lunch
Dinner
Snack
How often do you consume:
Cigarettes
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Drugs
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Coffee
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Pop
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Fruit juice
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Wine
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Beer
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Spirits
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Bottled Water
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Tap Water
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Tea
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Artificial Sweeteners
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Candy
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Fried food
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Fast Food
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Microwaved Food
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Dairy
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Chicken
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Fish
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Beef
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Pork
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Other Meat
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Eggs
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Wheat
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Grains
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Fresh Vegetables
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
Fresh Fruits
Never
Sometimes
Weekly
Every other day
Every day
Multiple times per day
What foods do you like?
What food do you crave?
What foods do you dislike?
Additional info (Anything else you want me to know?)
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