550 Biltmore Way · Suite 101
Coral Gables, FL 33134
Phone 305.446.9940 · facsimile 305.446.0861
Optimal Health Questionaire
In order to improve your health, how willing are you to:
very willing 5
4
3
Significantly modify your diet q q q Take several nutritional supplements each day q q q Modify your lifestyle (e.g., work, demands, sleep habits) q q q Engage in regular exercise q q q 2
q
q
q
q
1
not willing at all
q
q
q
q
Comments:
At the present time, how supportive do you think
the people in your household will be to your
implementing the above changes? very supportive
5
q
4
3
q q
2
1
q q
very unsupportive
Comments:
3 Day Diet Diary Instructions
It is important to keep an accurate record of your usual food and beverage intake as part
of your treatment plan. Please complete this diet diary for 3 consecutive days including one weekend day. Do not change your eating behavior at this time as the purpose of this food record is to
analyze your present eating habits. Record information as soon as possible after the food has
been consumed. Describe the food or beverage as accurately as possible e.g., milk what kind?
(whole, 2%, nonfat); toast - (whole wheat, white , buttered); chicken - (fried, baked, breaded) coffee
- (decaffeinated with sugar and ½ & ½). Record the amount of each food or beverage consumed
using standard measurements such as 8 ounces, etc. Include any additional comments about
your eating habits on this form (ex. Craving sweet, skipped meal and why, when the meal was at
a restaurant, etc).
Page 1
Day 1:
Diet Diary
Food Type
Amount consumed
Food Type
Amount consumed
Food Type
Amount consumed
Eating habits:
Day 2:
Eating habits:
Day 3:
Eating habits:
Page 2
Have you ever had a nutrition consultation?
q Yes
q No
Have you made any changes in your eating habits because of your health?
If yes, please describe:
Do you currently follow a special diet or nutritional program?
q Yes
q Yes
q No
q No
Check all that apply:
q Low Fat
q No Wheat
q South Beach Diet
q Low Carbohydrate
q Gluten Restricted
q Mediterranean Diet
q High Protein
q Vegetarian
q Low Sodium
q Vegan
q Specific program for weight loss/maintenance type
q Diabetic
q Ultrametabolism
q Paleo
q No Dairy
q Atkins
q other
Do you avoid any particular foods?
If yes, type and reason:
q Yes
q No
If you could only eat a few foods a week, what would they be?
Do you grocery shop?
If not, who does the shopping?
q Yes
q No
Do you read food labels?
q Yes
q No
Do you cook?
If not, who does the cooking ?
q Yes
q No
How many meals do you eat per day?
Page 3
Check all the factors that apply to your current lifestyle and eating habits:
q Fast eater
q Erratic eating pattern
q Eat too much
q Late night eating
q Dislike healthy food
q Time constraints
q Eat more than 50% of meals away from home
q Travel frequently
q Non-availability of health foods
q Do not plan meals or menus
q Reliance on convenience items
q Poor snack choices
q Significant other or family members
don’t like healthy foods
q Significant other or family members have
special diatery needs or food preferences
q Love to eat
q Eat because I have to
q Have a negative relationship to food
q Struggle with eating issues
q Emotional eater (eat when sad, lonely,
depressed, bored)
q Eat too much under stress
q Eat too little under stress
q Don’t care to cook
q Eating in the middle of the night
q Confused about nutrition advice
Exercise:
Current exercise program: activity (list type, number of sessions/ week, and duration of activity)
Activity type
frequency per week
duration in minutes
Stretching
Cardio/aerobics
Strength
Other ( yoga, pilates, gyrotonics, etc)
Sport or leisure activities
(golf, tennis, rollerblading, etc .)
Rate your level of motivation for including exercise in your life?
q Low
q Medium
q High
List problems that limit activity:
Do you feel unusually fatigued after exercise? if yes, please describe
q Yes Do you feel significantly less vital than you did a year ago? q Yes
Are you happy? q Yes
Do you feel your life has meaning and purpose? q Yes
Do you believe stress is presently reducing the quality of your life? q Yes
q No
q No
q No
q No
q No
Page 4
Do you like the work you do? q Yes
q No
Have you ever experienced major losses in your life? q Yes
q No
Do you spend the majority of your time and money to fulfill
responsibilities and obligations? q Yes
q No
Would you describe your experience as a child in your family
as happy and secure? q Yes
q No
Have you ever sought counseling? q Yes
q No
Are you currently in therapy? If yes, describe
q Yes
q No
Do you feel you have an excessive amount of stress in your life? q Yes
q No
Do you feel you can easily handle the stress in your life? q Yes
q No
Stress/coping
Daily stressors: Rate on scale of 1-10
work__________ family___________ social__________ finances__________ health__________ other_______
Do you practice meditation or relaxation technique? q Yes
q No If yes, how often_______________ Check all that apply: q Yoga q Meditation imagery q Breathing q Tai chi q Prayer q Other
Have you ever been abused, victim of crime, or experienced a significant trauma? q Yes
q No
Sleep/rest
Average number of hours you sleep per night ?_______________
Do you have trouble falling asleep? q Yes
q No
Do you feel rested upon awakening? q Yes
q No
Staying asleep? q Yes
q No
Page 5
Roles/relationship
Marital Status: q Single q Married q Divorced q Gay/lesbian q Long term partnership q Widow
Are you satisfied with your sex life? q Yes q No
How well have things been going for you?
overall
at school
in your job
in your social life
with close friends
with sex
with attitude
with your boyfriend/ girlfriend
with your children
with your parents
with your spouse
q very well
q very well
q very well
q very well
q very well
q very well
q very well
q very well
q very well
q very well
q very well
q fine
q fine
q fine
q fine
q fine
q fine
q fine
q fine
q fine
q fine
q fine
Enviromental and Detoxification Assessment
Do you have known adverse food reaction or sensitivities? if yes, describe symptoms
q poorly
q poorly
q poorly
q poorly
q poorly
q poorly
q poorly
q poorly
q poorly
q poorly
q poorly
q does not apply
q does not apply
q does not apply
q does not apply
q does not apply
q does not apply
q does not apply
q does not apply
q does not apply
q does not apply
q does not apply
q Yes q No
Do you have any food allergies or sensitivities? if yes, list all
q Yes q No
Do you have an adverse reaction to caffeine? q Yes q No
Do you have any known history of significant exposure to any harmful chemicals such as the following:
q Herbicides q Insecticides (frequent visits of exterminator) q Pesticides q Organic solvents
q Heavy metals q Other
Chemical name?
Date
Length of exposure
Do you or have you lived or worked in damp or moldy
environment or had other mold exposures? q Yes q No
Do you have any pets or farm animals? q Yes q No
Page 6
Smoking:
Currently smoking?
How many years? q Yes
q No
Packs per day: Previous Smoker: How many years?
2nd hand smoke exposure?
q Yes
Attempts to quit:
Packs per day:
q No
Alcohol Intake:
How many drinks currently per week? (1 drink = 5 ounces wine, 12 oz beer, 1.5 ounces spirits)
Other substances:
Caffeine intake?
q Yes
q No
Cups/day coffee; tea
q1
q 2-4
Soda or diet soda intake?
How many servings daily?
q Yes
q >4 a day
q No
In general, would you say your health is:
q Excellent
q Very good q Good q Fair q Poor
Compared to one year ago, how would you rate your health in general now? ( please check one box.)
q Much better than one year ago
q Somewhat better now than one year ago q About the same as one year ago
q Somewhat worse now than one year ago
q Much worse now than one year ago
How TRUE or FALSE is each of the following statements for you?
Definitely
True
I seem to get sick a little easier than other people
I am as healthy as anybody I know
I expect my health to get worse
My health is excellent q
q
q
q
Mostly Don’t know
True
q
q
q
q
Mostly False Definitely
False
q q
q
q q q
q q q
q q q
Page 7