| First Name |
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| Middle Name |
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| Last Name |
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| Telephone |
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| Email address |
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| Occupation |
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| Marital status |
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| Age |
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| Gender |
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Male
Female |
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| Height |
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| Have you experienced any changes in your weight in the last 6 months? |
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Weight loss of lbs
Weight gain of lbs
No change in weight |
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| If weight loss, was it planned |
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Yes
No |
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| Are you pregnant? |
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Yes
No
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| If yes, due date: |
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| Please list your five major health concerns in order of importance: |
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1.
2.
3.
4.
5. |
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| Have you had recent changes in appetite? |
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Yes
No |
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| Lifestyle |
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| How many times do you exercise per week (once, 2-4 times, 5 times, more) |
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| Types of physical activity or exercise you do |
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| Symptoms |
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| Do you experience heartburn or acid reflux |
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Yes
No |
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| Do you experience bloating shortly after eating |
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Yes
No |
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| Do you experience lump in throat |
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Yes
No |
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| Are you a vegetarian (no dairy, meat, fish or eggs) |
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Yes
No |
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| Do you feel like skipping breakfast |
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Yes
No |
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| Do you crave bread or noodles |
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Yes
No |
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| Do you crave chocolate |
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Yes
No |
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| Do you crave fatty or grease foods |
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Yes
No |
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| Have you been or are on low or reduced fat diet (past or present) |
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Yes
No |
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| Do you crave salty foods |
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Yes
No |
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| Do you crave sweets |
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Yes
No |
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| Do you binge or experience uncontrolled eating |
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Yes
No |
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| Do you have excessive appetite |
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Yes
No |
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| Do you crave coffee or sugar in the afternoon |
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Yes
No |
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| Are you irritable before meals |
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Yes
No |
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| Are you shaky if meals are delayed |
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Yes
No |
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| Do you experience frequent thirst |
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Yes
No |
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| Frequent urination |
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Yes
No |
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| Do you have difficulty gaining weight, even with large appetite |
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Yes
No |
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| Do you have difficulty losing weight |
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Yes
No |
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| Do you feel sleepy after meals |
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Yes
No |
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| Do you have chronic diarrhea |
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Yes
No |
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| Do you have diarrhea shortly after meals |
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Yes
No |
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| Do you have alternating constipation and diarrhea |
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Yes
No |
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| Is your stool hard or difficult to pass |
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Yes
No |
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| Are stools not well formed |
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Yes
No |
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| Do you have blood in your stool |
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Yes
No |
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| Are you having any problems with? If yes please check your problem. |
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Chewing
Swallowing
Nausea
Vomiting
Diarrhea
Constipation |
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| Do you experience pains in your stomach for which you use antacids occasionally |
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Yes
No |
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| Medical history |
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| Did you have your gallbladder removed |
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Yes
No |
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| Are you a recovering alcoholic |
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Yes
No |
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| Do you have a history of drug or alcohol abuse |
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Yes
No |
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| Do you have a history of hepatitis |
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Yes
No |
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| Have you used certain medications on a long-term basis, if yes please specify Yes |
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Yes
No |
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| Do you have pain under right side of rib cage |
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Yes
No |
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| Do you have food allergies |
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Yes
No |
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| Do you have Crohn's disease |
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Yes
No |
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| Do you have Celiac disease |
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Yes
No |
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| Do you have high blood pressure (normal 120/80) |
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Yes
No |
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| Are you lactose intolerant |
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Yes
No |
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| Do you have asthma, sinus infections |
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Yes
No |
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| Do you have a tendency to anemia |
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Yes
No |
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| Do you have family members with diabetes |
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Yes
No |
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| Do you suffer from depression |
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Yes
No |
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| Do you experience pounding heart |
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Yes
No |
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| Do you have history of kidney stones |
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Yes
No |
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| Do you have any of the following conditions? |
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| Allergies |
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Yes
No |
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| Anxiety |
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Yes
No |
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| Arthritis |
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Yes
No |
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| Asthma |
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Yes
No |
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| Cancer type |
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| Date of diagnosis |
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| Depression |
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Yes
No |
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| Diabetes or family history |
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Yes
No |
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| Faint spells, weakness |
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Yes
No |
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| Heart disease (heart attack, peripheral artery disease or family history, high cholesterol) |
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Yes
No |
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| Have you ever had a heart attack or stroke |
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Yes
No |
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| Do you have high triglycerides |
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Yes
No |
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| High blood pressure or family history |
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Yes
No |
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| Irritable bowel syndrome |
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Yes
No |
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| Low blood sugar |
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Yes
No |
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| Physical disability |
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Yes
No |
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| Surgery recently |
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Yes
No |
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| Do you have osteoporosis |
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Yes
No |
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| Are you menopausal or postmenopausal |
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Yes
No |
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| Do you have stomach or duodenal ulcers |
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Yes
No |
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| Do you have a hiatal hernia or do you experience a burning sensation in the throat or chest when you lie down |
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Yes
No |
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| Have you ever had high blood pressure |
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Yes
No |
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| Do you have respiratory allergies or asthma |
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Yes
No |
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| Behavioral aspects of nutrition |
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| Do you think you eat a lot more than other people do |
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| Do you feel you cannot stop eating once you have started. |
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| Do you feel you lose control of what and how much you eat. |
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| Do you eat until you feel very full |
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| Do you eat when you are not hungry |
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| When you are anxious, depressed, bored do you feel relief in eating |
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| Do you happen to hide the food you are eating because you feel guilty of the amount you are eating |
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| If you happen to binge eat you feel guilty or depressed |
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| Have you been binging for more than 6 months |
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| Do you happen to be binging more than twice a week |
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| Does this depress you, does it make you feel guilty |
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82-86 Wolcott Hill Road 
