HEALTH HISTORY/INTAKE
Name:___________________________________
Birthdate: _______________
Date:________________
Address ____________________________________ City, State, Zip _________________________________________
Email: ________________________________________
Phone (day): _____________________________________
Phone (evening): _______________________________
Best time to call: _________________________________
How did you hear about us (name, clinic, etc) : __________________________________________________________
Insurance company: ___________________________ Your doctor’s full name ________________________________
Have you seen a nutritionist before? _______If yes, who?__________________________________________________
Place of birth
Relationship status
Ethnic/cultural background
# of children
Occupation
Hobbies/life interests
Hours worked per week
Blood type
Weight
Weight 1 year ago
Do you consider yourself (check one):
Max Weight
 Normal Weight
Height
Lowest Weight
 Overweight
# of pets
Desired Weight
 Underweight
Spiritual/Religious practice
Medical Information
Date of last Physical Exam
Date of last Dental Exam
Date of last full bloodwork
Date of last Colonoscopy
Date of last Bone Density Exam
Date of last Mammogram/Thermography
Emergency contact
Phone
Describe all serious accidents, severe injuries, head injury,
fractures or broken bones (include date occurred):
MAIN CONCERNS:
List all serious illnesses, operations, and other operations,
and other hospitalizations you have experienced and
indicate year these occurred:
Please list (in order of important) the present health concerns, symptoms, or problems you are
experiencing:
How would you describe your general health & nutrition? ________________________________________
Stress Level (1-10, 10 being highest): _______ Energy Level (1-10, 10 being highest): _______
What treatments and/or other health care practitioners (medical doctor, naturopath, acupuncturist,
counselor, psychiatrist, chiropractor, herbalist, etc.) have you explored? How have they been helpful?
MEDICATION & SUPPLEMENTS: Please fill out separate Medications and Supplements Form.
ALLERGIES:
Drugs:
Foods:
Environmental Sources:
Other:
Women: Are your periods regular?
Y N
Painful or symptomatic?
Y N
How many days is your flow?
How frequent?
Please explain:
Men & Women:
Do you have any dietary restrictions?
Y N
If yes, please describe?
What diets have you tried in the past? What were the outcomes?
What role does exercise play in your life?
Do you currently or have you ever had an eating disorder, or experienced significant disordered eating patterns?
Do you drink, smoke, or have any major addictions? Have you in the past?
Please indicate frequency (0=never, 1= once/year, 2=several times/year, 3=monthly, 4=1-3 times/month, 5=daily or weekly):
Diet often
Are under excessive stress
Swallow food before chewing
well
Purge after eating
Hurried or rushed meals
Avoid eating
Are exposed to chemicals at
work
Have strong or uncontrollable
cravings
Use recreational Drugs
(specify):
Eat if bored. anxious or
depressed
Sneak or hide food
Do you like to cook?
SLEEP: How many hours of sleep do you get each night? _________ Do you sleep well? _________
What are your constraints if any. Please explain?_________________________________________
Do you wake up during the night?  Y  N If yes, how many times, at what time, and why (if known)?
__________________________________________________________________________________
What time do you wake? ________________ What time do you go to sleep?_______________
BM: Number of bowel movements : _______ (number) per ___________ (day, week, etc.)
Describe consistency and color (be descriptive, please)____________________________________
Do your BMs float or sink? _________________ Are they hard to pass/loose___________________
EXERCISE: How often do you exercise and what type?__________________________________________
_______________________________________________________________________________________
CURRENT DIET:
please list typical foods consumed on a regular basis
Do you follow a medically prescribed diet?  Y  N If yes, what is it?
Breakfast:_____________________________________________________________________________
Lunch: ________________________________________________________________________________
Snacks: _______________________________________________________________________________
Dinner: _________________________________________________________________________________
Desserts: _____________________________________________________________________________
Fluids: _________________________________________________________________________________
Alcohol: ________________________________________________________________________________
Where do you grocery shop?________________ What % of your food is home cooked?_________________
What types of restaurants do you like? _______________________________________________________
Describe your comfort level with cooking _____________________________________________________
Describe your current typical mealtime environment (peaceful, nurturing, rushed, chaotic, hostile, lonely,
irregular, etc.) ____________________________________________________________________________
What foods do you crave? ________________________________________________
What foods do you dislike?_______________________________________________
What foods do you love?_________________________________________________
CHILDHOOD DIET:
please list typical foods consumed on a regular basis
Breakfast:_____________________________________________________________
Lunch: _______________________________________________________________
Snacks: _______________________________________________________________
Dinner: _______________________________________________________________
Desserts: ______________________________________________________________
Fluids:
___________________________________________________________
Favorite foods: __________________________ Dislikes:________________________
Describe your childhood typical mealtime environment (peaceful, nurturing, rushed, chaotic, hostile, lonely, irregular,
etc.):__________________________________________________________________________________________
How many times per week DO YOU DRINK OR CONSUME (if more than 1 time in one day, count each time):
Artificial sweetener (i.e.
Splenda, Aspartame, etc) :
Olive Oil or coconut oil:
Dark chocolate:
What % cocoa?
Lard or beef tallow:
Carbonated beverages (nondiet):
Diet soft drinks:
Bread/Bagel (wheat, white,
whole grain?):
Frozen dinners:
Sauerkraut, kim chee, miso
kombucha:
Cooked whole grains:
Candy (other than dark
chocolate):
Vegetable oil (other than
olive):
White rice, pasta, crackers,
cold breakfast cereals:
Energy drinks:
Pastries, cinnamon rolls,
doughnuts, desserts:
Beans (legumes)/lentils:
Potatoes, beets, other root
veggies:
Potato chips/pretzels:
Pizza:
Coffee (decaf or reg?):
Meals out:
Raw veggies:
Cooked veggies:
Eggs:
Tofu, tempeh, edamame:
Meat (Beef, pork, lamb,
venison…):
Added sugar:
Margarine (list brand) :
Corn chips, corn bread, corn
tortillas:
Protein shakes (whey, soy,
pea, rice, hemp?):
Cheese:
Natural sweeteners (honey,
etc.) :
Luncheon meats, hotdogs,
bologna:
Butter:
Fast food:
Chew tobacco:
Milk, cream or Ice Cream
(dairy only):
Fried foods:
Fresh/frozen fruit:
Canned fruit/veggies:
Peanuts:
Tea (black, green or herbal?):
Fish/seafood (fresh/farmed?):
Water (tap, filtered, bottled?):
Nuts (except peanuts,
raw/roasted?) :
Other:
Yogurt, kefir, buttermilk:
Fake vegan meats:
PAST MEDICAL HISTORY:
Y
Measles
Mumps
Chickenpox
Whooping Cough
Scarlet Fever
Diptheria
Smallpox
Blood Transfusions
Heart Disease
Depression
Venereal Disease (STD’s)
N
Y
N
Hives or Eczema
Tuberculosis
Diabetes
Cancer
Polio
Glaucoma
Hernia
Kidney Disease
Bleeding tendency
Anxiety
Exposure to environmental toxin
Y
N
chest x-ray
Infectious Mono
Rheumatic Fever
Mitral Valve Prolapse
Stroke
Hepatitis
Thyroid Disease
AIDs or HIV+
Anemia
Bipolar
Any other disease (please list): ___________________________________________________________________________________
DIGESTIVE SYSTEM:
Y
Are you on a vegan diet (no animal products at all)?
Do you feel like belching, or are you bloated after eating?
Do you see undigested food or a greasy film in the toilet?
Do you lose weight easily or is it hard to gain weight?
Do you get heartburn/acid reflux? Times per week:
Are your fingernails soft, brittle or have white spots?
Are you prone to muscle cramps? Which muscles:
Do you have poor night vision?
Do you have or have you had an Ulcer?
Do you have a hiatal hernia?
N
Comments
Do you have or have you had gall bladder disease?
Do you have thyroid problems (that you know of)?
FAMILY HISTORY:
who
Alcohol or Drug Problem
Allergies
Anemia
Ankylosing Spondylitis
Anxiety disorders
Asthma
Autoimmune disorders (type?)
Cancer (type?)
Chronic Lung Disease
Depression/mood disorders
Diabetes (type?)
Digestive disorders
Disordered eating
Eczema
Epilepsy
Gallbladder
Glaucoma
Gout
Heart Disease
High Blood Pressure
Present age /or Age of death
who
High Cholesterol
Hepatitis
HIV/AIDS
Kidney Disease
Leukemia
Mental Illness- other
Migraine Headaches
Multiple Sclerosis
Muscular Dystrophy
Obesity
Osteoporosis
Psoriasis
Parkinson’s disease
Rheumatoid Arthritis
Sinus issues
Stroke
Thyroid Disease (type?)
Tuberculosis
Ulcers
Other
If living, health (good, fair, poor)
Father:
Mother:
Sibling1:
Sibling2:
Sibling3:
Spouse:
Child1:
Child2:
Child3:
What brings you joy, comfort, or relaxation?
If deceased, cause of death
What barriers (mental, emotional, family-related, schedule-related, etc) have you encountered in
the past, or foresee in our work together, in achieving your health goals?
If you overcame these challenges and achieved these goals, how would your life be different?
Is there anything else that would be helpful for me to know about you?
Thank you for taking the time to fill this out. Please be sure to fill out the form on the following
page as well. We look forward to working with you!
Medications & Supplements List
Name:____________________________________ Date of birth:___________________ Date:____________________
Please indicate if you have EVER taken any of the following Medications:
Medication Type
Antacids
Aspirin/Tylenol
Heart Medications
Lithium
Relaxants/Sleeping
Pills
Antibiotic/Antifungal
Chemotherapy
High Blood Pressure
Oral Contraceptives
Thyroid
Antidepressants
Cortisone
Hormones
Radiation
Pain Medication
Antidiabetic/Insulin
Anti-Inflammatories
Laxatives
Recreational Drugs
Ulcer Medication
Other:
Medication Name
Current Dose
Date Started
Date Discontinued
Please list any Supplements you are currently taking:
Supplement
Brand
Current Dose
Date Started