Nutrition Client Form
Date:
Name:
(If known) Height:
Weight:
**If you have already filled out the below information in the Chiropractic New Client Form, please skip to ‘Goals and
Readiness to change’
Address:
Contact number:
Email address:
How young are you?
Occupation:
Are you currently pregnant? ---
No. of Children:
Marital status:
GOALS & READINESS TO CHANGE:
What are your main goals for this consultation?
What are your over all health goals?
What are some of the challenges you face in altering your habits? (eg. Time poor, lack of ideas, lack of skills)
What have you previously done to reach your goals?
MEDICAL HISTORY:
Previous Surgery?
Are you currently taking any medication, or have you taken any in the last 6 months?
List any supplements or herbal remedies that you are currently taking:
Do any disease/illnesses run in your family? (eg. Depression, heart disease, obesity)
HEALTH CONCERNS:
Severity (scale 1 very mild-10 severe)
0
0
0
0
1.
2.
3.
4.
LIFESTYLE:
How often do you exercise?
Type Frequency Duration Intensity Individual or group Does anything limit you from being physically active?
On average, how many hours of sleep do you get?
Are you a smoker? --- Previously?
For how long?
How much Alcohol do you consume?
- Weekly:
- Daily:
DIET HISTORY:
D = Consume daily.
W = Consume weekly.
FD = Consume a few times a day. FW = Consume few times per week.
M = Consume monthly
FM = Consume few times per month
Alcohol ---
Milk ---
Fast Food ---
Organic Foods ---
Coffee & Tea ---
Eggs ---
Bread ---
Fruit ---
Soft Drinks ---
Cereal ---
Beef ---
Raw Vegetables ---
Refined Sugar ---
Diet Foods ---
Poultry ---
Whole Grains ---
Artificial Sweetener ---
Fasting---
Cheese---
Seafood ---
Are you Vegetarian or Vegan?
‘
Do you have any food allergies, sensitivities or intolerances?
Who does most of the cooking? – do you find cooking difficult?
How often do you eat out or get takeaway?
List 3 things that you would change with your current health and nutrition habits?
1.
2.
3.
The nutrition/eating habits that are most challenging for me:
The nutrition/eating habits that I am most pleased with:
Food Cravings?
Food Dislikes?
Have you experienced any of the following?
(Indicate: FR – Frequent, HH – Have had)
Fever ---
Fatigue ---
Colds/flu ---
Heartburn ---
Fatigue ---
Itchy eyes ---
Constipation ---
Loss of appetite ---
Allergies ---
Stomach cramps ---
Extreme thirst ---
Itchy rashes ---
Bloating/gas ---
Difficulty sleeping ---
Dizziness ---
Reflux ---
Nausea ---
Diarrhoea ---
Rapid weight loss ---
Weakness ---
How do you grade your current dietary intake? (Out of 10) 0
Has your diet improved or deteriorated over the last 5 years? --What has been different?
Is there anything else you would like to mention which hasn’t been discussed?
Thank you for your time!
Rapid Weight gain ---