Nutrition Intake Questionnaire
Today's Date
*
-
Month
-
Day
Year
Date Picker Icon
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Genetic Background
*
African American
Native American
Mediterranean
Hispanic
Caucasian
Northern European
Asian
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Preferred Primary Phone
*
-
Area Code
Phone Number
Secondary Phone
-
Area Code
Phone Number
Fax
-
Area Code
Phone Number
E-mail
*
Best way to contact?
*
Would you like to be added to my email list?
*
Yes
No
How did you hear about Thrive Nutrition & Wellness, LLC / Andrea Langston, MS, CNS?
*
Primary Physician
*
Name
Email
Phone
City
Other Pertinent Provider
Name
Email
Phone
City
Other Pertinent Provider
Name
Email
Phone
City
Back
Next
Save
Complaints / Concerns
What do you hope to achieve in your visit(s)?
*
If you could experience one change in two weeks, what would it be?
*
Reflection
Name the three main health/nutrition concerns you would like to remove from your life if you could, with one being the first priority to resolve.
*
When was the last time you felt well?
*
Additional Comments:
Did something trigger your change in health?
*
What makes you feel better?
*
What makes you feel worse?
*
Back
Next
Save
Personal Health History
Height
*
Current Weight
*
Ideal Weight
*
Highest Adult Weight, Year
*
Lowest Adult Weight, Year
*
Relationship Status
*
Who do you share your home with (include people and animals)
*
What health concerns did you experience as a child?
*
What health concerns have you experienced as an adult?
*
Please list any medical diagnoses:
*
Please list any allergies (food / medication / chemicals / environmental):
What is your typical reaction and how severe is it (1-10)?
Women Only
WOMEN: Pregnancies (please also include losses/terminations)
Rows
Year
Vaginal/C-Section
Sex of Baby
Complications/Comments
1
2
3
4
5
Are you currently pregnant?
Yes
No
Actively trying to conceive?
Yes
No
Breastfeeding?
Yes
No
Medical History
Please list any surgeries you have undergone and the dates:
Have you ever been hospitalized for reasons other than the surgeries/operations? Please include reasons and dates:
Have you ever had a major chemical exposure? If yes, please list what and when:
Are you part of a recovery program? If so, which one?
Please list any countries you have lived in or visited outside of the US, including dates:
Is there anything that has surfaced during a recent medical test, lab work or doctor's visit that you would like to report?
Family Health History
Click to Edit
*
Rows
Alive/Deceased
Present Health/Cause of Death
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Mother
Father
Sisters
Brothers
Children (inc. ages)
Back
Next
Save
Current Nutrition & Lifestyle
Do you smoke or use nicotine?
*
Yes, cigarettes
Yes, other
No and I never have
No, but I have in the past
Do you drink alcohol?
*
No
Yes, less than once/month
Yes, a few times per month/once a week
Yes, on weekends
Yes, most days
Yes, every day
Yes, multiple drinks/day
Other
Do you use recreational drugs?
Current Medications (OTC and Prescription)
Rows
Medication
Dosage
Frequency
Year Started
Reason Taking
1
2
3
4
5
6
7
8
Please list any medications you have taken in the past for a considerable amount of time (birth control, antibiotics, steroids, acid-blocking drugs, Tylenol, aspirin, etc)
Have you been on antibiotics recently?
*
Have you been on antibiotics 5 or more times during adulthood?
*
As a child, were you on antibiotics more than 5 times?
*
Current Supplements
Rows
Name/Brand
Dosage
Frequency
Year Started
Reason Taking
1
2
3
4
5
6
7
8
Back
Next
Save
Physical Activity
How many times per week do you exercise?
*
How long do you typically exercise at one time?
Do you enjoy exercising?
*
Are you satisfied with your energy level?
*
Please indicate the type of exercise you are currently engaging in.
Rows
Type/Intensity (low/mod/high)
# Day Per Week
Duration (mins)
Stretching/Yoga
Cardio/Aerobics
Strength Training
Sports or Leisure
Other
Note any problems that limit your physical activity:
How would you categorize your activity level?
*
Please Select
Sedentary
Mildly Active
Moderately Active
Very Active
Intensely Active
Back
Next
Save
Daily Stressors
Rate on a scale of 1 (low) to 10 (high)
Work
*
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
Family/Social life
*
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
Health
*
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
Life Overall
*
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
Is there any unusual excess stress in your life?
*
Please Select
Yes
No
If yes, please explain:
Do you easily handle stress?
*
Please Select
Yes
No
What do you do to relax or relieve stress?
*
What nourishes you?
*
Back
Next
Save
Please list any major events that have occurred in your life over the past 10 years, including the approximate dates they occurred. You can include earlier items if you feel they impacted you greatly. Include illness, medical conditions, births, deaths, marriage, divorce, accidents, moves, job changes, miscarriages, and anything else you feel greatly impacted your life.
*
Rows
Date
Event
Sleep
What time do you typically go to bed?
*
Time you fall asleep:
*
Time of alarm:
*
Time out of bed:
*
Do you wake up during the night?
*
Please Select
Yes
No
If yes, how many times?
Reasons for waking?
How would you rate the overall quality of your sleep? (0-low, 5-high)
*
Do you feel rested upon waking?
*
Food and Nutrition
Who does the cooking in your household?
*
Do you like to cook?
*
Are you currently following a special diet/food plan?
*
Have you followed any special diets/food plans in the past? If so, please list.
*
How many times per week do you eat the following meals out:
Rows
Meals Per Week Eaten Out/Take Out
Breakfast
Lunch
Dinner
Back
Next
Save
Symptom Questionnaire
Please check off any symptoms experienced somewhat regularly.
Section 1
Indigestion, burping, bloating or sleepy immediately after meals
Heartburn or acid reflux
Tendency to allergies, eczema, asthma
Nausea in the evenings
Proteins hard to digest, complex meals hard to digest (protein and carbs)
Loss of taste for meat
Sense of excess fullness after meals
Feel like skipping breakfast, overall low appetite
Undigested food in stool
Anemia, unresponsive to iron
Section 2
Nausea in the morning
Heartburn or acid reflux
Strong appetite, demanding hunger, excess salivation
Aggravated by spice or sour, sour burps, sour smell
Section 3
Pain between shoulder blades
Stomach upset by fatty or fried foods
Loose stools with fatty foods, irregular stools, fat in stools (shiny, floating), smelly stools
Nausea
Light, clay-colored or greenish/yellow stools
Dry skin, itchy feet or skin peeling on feet
Gallbladder attacks
Have had gallbladder removed
Bitter taste in mouth, especially after meals
Easily intoxicated or hungover if you drink wine
Pain under right side of rib cage
Hemorrhoids or varicose veins
Sensitive to chemicals (perfume, cleaning agents, etc), diesel fumes, or tobacco smoke
Section 4
Food allergies or sensitivities
Frequent intake of allergenic food(s), strong attachment to allergenic foods
Cravings, addiction or binging of allergenic food(s)
Abdominal bloating 1-2 hours after eating
Pulse speeds up after eating
Crohn's disease, frequent sinus infection, migraines, asthma
Airborne allergies
Hives
Section 5
Catch colds at the beginning of winter
Frequent colds, flu, or other infections (sinus, ear, bladder, skin, etc)
Experience a mucous producing cough
Never get sick
History of Epstein Bar, Mono, Herpes, Shingles, Chronic Fatigue Syndrome, Hepatitis
Chronic viral conditions
Food allergies or sensitivities
Section 6
Coating on your tongue
Fungus or yeast infections
Yeast symptoms increase with sugar, starch or alcohol consumption
Less than one bowel movement a day
Excessive foul smelling gas
Irritable bowel syndrome or colitis
Bad breath or strong body odor
Cramping in lower abdomen
Stools are difficult to pass
History of parasites
Stools have corners or edges, are flat or ribbon-shaped
Section 7
Eat less than 5 servings (1/2 cup cooked/1 cup raw) vegetables/fruits per day
Crave sweets, breads, rolls, cookies, pasta, pizza or chips
Crave coffee or sugar in afternoon
Fatigue is relieved by eating
Binging or uncontrolled eating
Excessive appetite
Sweets and snacks give you temporary boost followed by a crash
Headache, irritability, or shakiness if meals are skipped or delayed
Heart palpitations after eating sweets
Frequent thirst
Frequent urination
When eating carbs or sweets, feel like you can't stop
Tend to gain weight in the belly
Pre-diabetes, diabetes, PCOS, hypoglycemia, or alcoholism (or family history of any)
Elevated triglycerides or cholesterol
High blood pressure
Section 8
High or low blood pressure
Low or decreased libido
Trouble falling asleep
Sleep less than 8 hours per night
Frequently go to bed after midnight
Get less than 1 hour of sunlight per day
Work the night shift
Are an emotional eater
Feel anxious or have panic attacks
Shallow breather
Experience heart palpitations
Cravings for salt or sweet
Experience chronic or prolonged fatigue
Fatigue prevents you from doing things you would like - interferes with work, family or social life
Feel like you can't get started in the morning without coffee or caffiene
Section 9
Cold when everyone else is warm
Coarse or brittle hair
Constipation
Thinning hair or hair loss
Loss of outside of eyebrow
Lower libido
Depression
Difficulty losing weight
Low blood pressure or heart rate
Elevated cholesterol
Hoarse voice
Dry, scaly skin
Cold hands and feet
Experience fatigue
Fluid Retention
Section 10
Aware of irregular or heavy breathing
Experience discomfort at high altitudes
Sigh frequently or "air hunger"
Have shortness of breath with moderate exercise
Experience swelling of ankles, especially at end of day
Blush or face turns red for no reason
Experience dull pain or tightness in chest and/or radiates into left arm, worsens on exertion
Muscle cramps on exertion
Section 11
Rarely break out into a sweat
Use aluminum cooking equipment
Have mercury tooth fillings (silver)
Heat food in plastic containers in microwave
Have clothes dry-cleaned
Eat "fast food" more than twice per week
Drink tap, well, or bottled water
Strong body odor
Acne on face or buttocks
Drink less than 4 cups of water per day
Live in a large urban or industrial area
Use lawn or garden chemicals
Have less than one bowel movement per day
React to small amounts of alcohol
Sit at computer 3+ hours per day
Exercise less than 3 times per week
Use tobacco products
Eat large fish more than once per week (swordfish, tuna, shark, tilefish)
Urinate small amounts of dark urine only a few times per day
Frequently exposed to solvents and chemicals at work or home
Feel any of the following when using caffeine: wired, aches in muscles or joints, anxiety, palpitations, sweating, dizziness
Have negative reaction to foods containing MSG, sulfites, or other preservatives
Back
Next
Save
In order to improve your health, how willing are you to:(Rate on scale of 5-very willing to 1-not willing)
*
Rows
5
4
3
2
1
Significantly modify your diet
Take nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (work demands, sleep habits, exercise)
Practice a relaxation technique
Engage in regular exercise/physical activity
Have periodic lab tests to assess your progress
Do you believe your current health is largely in your control or out of your control?
*
What do you think would make the most difference in your overall health?
*
Have you taken any steps to improve your health? Please explain.
*
How often do you eat the following? Type a number under Day, Week, or Month to indicate how often you eat an item. Example: type "1" under "Day" if you eat one serving of an item on an average day. Type "1" under "Week" if you eat something approximately once per week, etc.
*
Rows
Day
Week
Month
Nuts or Seeds
Lentils/Beans
Yogurt
Oils/Butter
Cow's Milk
Non-Dairy Milk
Eggs
Cheese
Ice Cream
Pasta
Chips/Crackers/Pretzels
Candy/Sugar
Fast Food
Soy Products (tofu, miso, etc)
Bread
Whole Grains (rice, quinoa, oats, etc)
Total Veggies
Root Veggies (potatoes, beets, carrots)
Total Fruit
Berries
Coffee
Tea
Soft Drinks
Frozen Dinners
Alcoholic Drinks
Fermented Foods (sauerkraut, kombucha, etc)
Shellfish
Fish
Organ Meat
Deli Meat
Chicken/Turkey
Red Meat
How many meals do you typically eat per day?
*
How many snacks do you typically eat per day?
*
How many ounces of water do you drink per day, on average?
*
Please list any foods that you do NOT like:
*
How would you describe your eating habits?
*
On a scale of 1 to 10 (10 = nourishing and healthy), rate your current diet.
*
Please Select
1
2
3
4
5
6
7
8
9
10
How willing are you to make changes? (10 = very willing)
*
Please Select
1
2
3
4
5
6
7
8
9
10
Patient Narrative
Please SHARE any additional information about your health and medical story that would help us help you. SHARE your challenges and goals you would like to accomplish on this journey to wellness.
*
Back
Next
Save
3-Day Food Journal
Please record all food and drink consumed, including water.
Record info as soon as possible after eating.
Do not change your eating behavior. The purpose of this food record is to help me understand your current eating habits.
Describe the food or beverage consumed (kind, condiments, method of cooking (i.e. baked, fried, etc)).
Record the amount of each food consumed using standard measurements (cups, onces, Tbsp, tsp) to the best of your ability.
Click to edit.
Rows
Day 1
Day 2
Day 3
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Save
Submit
Should be Empty: