Nutrition Intake Questionnaire

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?*

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)

	Year	Vaginal/C-Section	Sex of Baby	Complications/Comments
1
2
3
4
5

Are you currently pregnant?
Actively trying to conceive?
Breastfeeding?
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*

	Alive/Deceased	Present Health/Cause of Death
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Mother
Father
Sisters
Brothers
Children (inc. ages)

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.

	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 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.*

	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?*
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:

	Meals Per Week Eaten Out/Take Out
Breakfast
Lunch
Dinner

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.

	Day 1	Day 2	Day 3
Breakfast
Snack
Lunch
Snack
Dinner
Snack

Should be Empty:

	Medication	Dosage	Frequency	Year Started	Reason Taking
1
2
3
4
5
6
7
8

	Name/Brand	Dosage	Frequency	Year Started	Reason Taking
1
2
3
4
5
6
7
8

	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

	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

Nutrition Intake Questionnaire

Complaints / Concerns

Reflection

Personal Health History

Women Only

Medical History

Family Health History

Current Nutrition & Lifestyle

Physical Activity

Daily Stressors

Sleep

Food and Nutrition

Symptom Questionnaire

Patient Narrative