Nutritional Questionnaire First Name Last Name Address City State Zip Phone Email Date of Birth Height (ft-in) Current Weight (lbs) Goal Weight (lbs) Cholesterol, HDL/LDL Triglycerides Blood Pressure Blood Type Do you have: (Y/N - Details if applicable) Diabetes/Hypogylcemia? Food Allergies/Intolerances? Environmental Allergies? Other significant lab results? Do you have a medical diagnosis? (if yes, please explain) Are you pregnant? (if yes, how far along?) Do you have children? How many? What are their ages? Please list 3-5 main health goals and/or reasons you are seeking nutrition coaching. I.E. Specific health issues, dietary, lifestyle, behavioral, stress, family, nutrition questions/understandings etc. Please list any digestive symptoms (if any) I.E. bloating, burping, constipation, acid reflux, GERD etc.) What do you crave? What time of day are your cravings? Have you ever implemented calorie restrictions, counting weight gain, yo-yo dieting? (If yes, please list) Eating disorder, binging, purging? (if yes, how often and how long?) Hormonal/menstrual issues such as PMS, menopause, bone density? (If yes, please list) Are you a vegan/vegetarian? If yes, for how long and are you open to adding animal product into your diet? Addictions: tobacco, drugs, alcohol, food, etc? (if yes, please specify) Have you ever experienced: (check all that apply) Thyroid or adrenal issuesLow energyInability to focusSleep issuesDepressionHeadaches/migrainesMood swingsAnxiety/panic attacks Anything else we should know about your eating habits? Please list medications you are taking now and in the recent past - name, dose, reason for taking, how long, benefits, side effects. Please list any vitamins or supplements you are taking now or in the recent past - name, dose, reason for taking, how long, benefits/side effects. Do you eat any of the following foods on a daily or regular basis? (Check all that apply) Wheat/glutendairySugarSoyEggsCornArtificial sweetenersPeanutsShellfishNightshades (eggplant, tomato, potato, peppers) Are you in therapy, 12-step, physical therapy, or any other therapy now or in the past? Please elaborate. Have you ever worked with a nutrition consultant or alternative health practitioner? Please elaborate on your experience and outcomes, were they positive? Toxic Exposure Questions Have you had exposure to any toxins (pesticides chemicals, heavy metals, plastics, inhaled chemicals, industrial chemicals) that you are aware of at your home of place of employment? If yes, explain. Have you had any recent vaccinations including flu shot, COVID-19 shot in the last few years? Please list. Have you recently remodeled or plan to remodel your home? If yes, please explain. Bacterial Balance Questions How many times have you taken antibiotics over the course of your life? Estimate either number of times or number of years. Do you have/get yeast overgrowth (yeast infections, nail fungus, athlete's foot) now or in the past? Please specify. Have you ever been on birth control pills? If yes, indicate number of years/months. Lifestyle Questions Do you exercise regularly? If yes, indicate number of hours, number of times per week. What type of exercise? Do you have difficulty falling asleep? Staying asleep? Please elaborate. What gives you the most stress? What do you do to relieve/reduce stress? Nutrition Please indicate a typical weekday meal for each time of day. Breakfast: Lunch: Dinner: Snacks: Please indicate a typical weekend meal for each time of day. Breakfast: Lunch: Dinner: Snacks: Please indicate time of day snacks are eaten (check all that apply) MorningMid-morningAfternoonMid-AfternoonEveningLate Night Daily liquid intake (# of 8-oz glasses typically consumed each day) Non-alcoholic beverages (check all that apply) WaterMilkFruit juiceSports/energy drinksRegular sodaDiet sodaRegular coffeeDecaf coffeeRegular teaDecaf teaHerbal teaOther If other, please list Alcoholic Beverages consumed during the week WineBeerLiquor Average amount of alcohol per weekday Alcoholic beverages consumed during the weekend WineBeerLiquor Average amount of alcohol per weekend day List your favorite foods List the food you dislike Describe your intake of fast foods and processed food (what kind, how much, how often) How often do you eat in restaurants in a typical week and what types of restaurants do you go to? What do you typically eat at restaurants? Have you tried any weight management programs in the last 10 years? If yes, list programs and success rate. Describe any known food allergies and prohibitions (ie no red meat, lactose intolerance, etc) What dietary habits would you like to change?