1. Have you lived or traveled outside of the United States? If so, when and where?:
2. Have you or your family recently experienced any major life changes? If so, please comment:
3. Have you experienced any major losses in life? If so, please comment:
4. How much time have you had to take of from work or school in the last year?
0 to 2 days3 to 14 daysmore than 15 days
5. What are your main health concerns? (Describe in detail, including the severity of the symptoms):
6. When did you first experience these concerns?
7. How have you dealt with these concerns in the past?
8. Have you experienced any success with these approaches?
9. What other health practitioners are you currently seeing? List name, specialty and phone # below.
10. Please list the date and description of any surgical procedures you have had.
11. How often did you take antibiotics in infancy/childhood?
12. How often have you taken antibiotics as a teen?
13. How often have you taken antibiotics as an adult?
14. List any medicine you are currently taking:
15. List all vitamins, minerals, herbs and nutritional supplements you are now taking:
16. Have any other family members had similar problems (describe)?
17. Are there any foods that you avoid because of the way they make you feel?
If yes, please name the food and the symptom:
18. Do you have symptoms immediately after eating like bloating, gas, sneezing or hives?
If so, please explain:
19. Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so, please explain:
20. Are there foods that you crave? If so, please explain:
21. Describe your diet at the onset of your health concerns:
22. Do you have any known food allergies or sensitivities?
23. Which of the following foods do you consume regularly?
sodadiet sodareined sugaralcoholfast foodgluten (wheat, rye, barley)dairy (milk, cheese, yogurt)coffee
24. Are you currently on a special diet?
ovo-lactodiabeticdairy restricted or dairy-freevegetarianveganpaleoblood typerawreined sugar-freegluten-freeOther (please describe)
25. What percentage of your meals are home-cooked?
26. Is there anything else we should know about your current diet, history or relationship to food?
27. Bowel Movement Frequency
1–3 times per daymore than 3 times per daynot regularly every day
28. Bowel Movement Consistency
soft & well formedoften loatdifficult to passdiarrheathin, long or narrowsmall and hardloose but not wateryalternating between hard and loose
29. Bowel Movement Color
medium brownvery dark or blackgreenishblood is visiblevariableyellow, light brownchalky coloredgreasy, shiny
30. Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc:
31. Please check any of the following conditions that apply to your history and briefly describe your symptoms, chosen treatment(s), and dates.
CancerHeart DiseaseHepatitisVenereal DiseaseDiabetesHigh Blood PressureHigh CholesterolKidney DiseaseThyroid DiseaseDepressionAsthmaAllergiesAnemiaChronic Yeast Infections
32. Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)?
33. Do odors affect you?
34. Are you or have you been exposed to second-hand smoke?
35. Do you have mercury amalgam illings?
36. Have you had periods of eating junk food, binge eating or dieting? List any known diet that you have been on for a significant amount of time.
37. Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?
38. How do you handle stress?
39. Describe your sleep patterns. Can you get to sleep easily? Can you stay asleep? How many hours do you average per night?
40. How are/were your menses? Do/did you have PMS? Painful periods: If so, explain.
41. In the second half of your cycle do you experience any symptoms of breast tenderness, water
retention or irritability?
42. Have you experienced any yeast infections or urinary tract infections? Are they regular?
43. Have you/do you still take birth control pills: If so, please list length of time and type.
44. Have you had any problems with conception or pregnancy?
45. Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list again here.
46. Do you have any concerns or issues with your sexual functioning that you’d like to share with us (pain with intercourse, dryness, libido issues, erectile dysfunction)?
47. Is there anything else about your sexual history that would be helpful for us to know in your health history?
48. How are your moods in general? Do you experience more than you would like of anxiety? Depression? Anger?
49. On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy.
50. At what point in your life did you feel best? Why?
51. Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain, if no.
52. Who in you family or on your health care team will be most supportive of you making dietary
53. Please describe any other information you think would be useful in helping to address your
54. What are your health goals and aspirations?
55. Though it may seem odd, please consider why you might want to achieve that for yourself:
Nutritional Intake Form
Food / Mood / Poop Journal
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