Lifestyle and Nutritional Assessment FormDear Client: Please read the instructions of each form carefully and complete this questionnaire with care. Your answers will help me determine the most effective recommendations to make based on your main health concern(s) presented. This health history record is protected and kept strictly confidential. It will not be released without your consent.

Name:       Date:      

Telephone (Home):       (Work):       (Cell):      

Email:      

Age:      

Sex: M F

Height:      

Weight:      

Appointment Reminders? No Email Phone AHS Quarterly Newsletters? Yes No

Please answer each question carefully and LEAVE BLANK those that don’t apply to you.

LIFESTYLE:What is your #1 goal you want to achieve during our time together?      

What are your main health concerns? Please list concerns in priority and when they started:

1.       4.      

2.       5.      

3.       6.      

Have you ever experienced any major trauma?      What level of stress do you currently experience? Please quantify on a scale of 1 (low) to 10 (high):   What are the major causes of your stress?      How does your stress manifest (show)?      What coping mechanisms do you implement?      Do you vacation regularly? Yes No What was your last vacation?      

What is your current exercise routine? (Include type, frequency and duration)      

Are you satisfied with your present weight? Yes No Do you wish to gain weight? lose weight? If so, how much?      

How would you describe your energy levels on a scale of 1 (low) to 10 (high)?   Do you experience any lulls or highs in energy levels throughout the day? Yes No If so, what time(s) of day?      

How many hours on average do you sleep daily?      Do you: have difficulty falling asleep? Staying asleep? Awaken feeling unrested? Snore?

What is your occupation?      What do you enjoy/not enjoy about work?      How many hours each week do you work?      Do you work shifts? Regular schedule?

Do you smoke? Yes No If yes, how much and for how long?       How do you feel about smoking?      

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Are you ever exposed to smoke at home or at work? Yes No Do you use recreational drugs? Yes No If yes, please describe:      Have you ever been treated for: drug dependency? Alcohol dependency?

How many hours do you spend daily, on average: Driving?      Watching TV?      

Reading?      On a computer?      

Sitting at a desk?      

What is your current morning routine?       Evening routine?      

What are your interests and hobbies? Please list:      How much free time do you feel you have in a day?      If need be, how would you make more time for yourself?      Do you regularly check in with yourself (self-reflect)? Yes No Need reminders to do so Time permitting, what would you like to incorporate into your day?      

MEDICAL HISTORY:Are you currently taking medication (including birth control)? Yes No

Name of Prescription Medication

Reason(s) for Medication Duration of Medication

                                                                                     

Have you taken antibiotics over the past 5 years? Yes No If yes, when were they last taken and the reason for taking it?      

Are you currently taking Natural Health Products (NHPs)? (Includes vitamins, minerals, herbs and homeopathic remedies) Yes No

Name of NHP Reason(s) for NHP Daily Amount/Dose                                                                                     

Do you have any allergies or sensitivities (including to medication)? Yes No If so, please list:      Are you anaphylactic (life-threatening allergy)? If so, to what:      

Do you have any silver-mercury fillings? Yes No If so, how many and for how long?      Do you have any root canals? Yes No If so, how many and for how long?      

Have you ever been:a) Diagnosed with an illness? Yes No If so, please explain:      b) Hospitalized? Yes No If so, for what reason:      

Have you had surgery to remove your gall bladder? Tonsils? Appendix? If so, explain:      

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Have you experienced fungal infections (Ex. Jock itch, Athlete’s foot)? Yes No If so, please describe:      Have you experienced a decline in sexual interest? Yes No Have you had kidney stones or gallstones? Yes No If yes, please describe:      

How often do you have a bowel movement daily?      Do you strain to have a bowel movement? Yes No Occasionally Related to particular food or circumstance?      Do you have loose bowel movements? Yes No Occasionally Related to particular food or circumstance?      Is there undigested food in your stools? Yes No Occasionally Other bowel-related concerns? (Colour, blood, oily, etc.)      

FAMILY HISTORY: Use “F” for father, “M” for mother, “S” for sibling, “G” for grandparent, “O” for other(s):

      Allergies       Diabetes       Intestinal Disease

      Alcoholism       Drug Abuse       Kidney Dysfunction

      Arthritis       Gall Bladder Issues

      Mental Illness

      Asthma       High Cholesterol

      Osteoporosis

      Autoimmune Disease

      Heart Disease       Skin Conditions

      Cancer       Hypertension       Ulcers

Type(s) of Cancer:       Other condition(s):      

FEMALES:Are you pregnant? Yes No Are you currently breastfeeding? Yes No Have you noticed any changes in menses? (Ex. Frequency, duration, flow, clotting, etc.) Yes No If so, please specify:      Do you suffer from PMS symptoms? Please specify:      Are you pre-menopausal? Yes No Post-menopausal? Yes No Are you experiencing any menopausal symptoms? Yes No If yes, please specify:      Have you had a bone density test? Yes No If yes, what was the result?      

MALES:Have you experienced any prostate problems? (Ex. frequent urination, discomfort during urination) Yes No If yes, please describe:      

NUTRITIONAL AND DIETARY HABITS:How many times a day do you eat, on average? Main meals:     Times of day:      Snacks:     Times of day:      

Provide examples of your typical meals and snacks:Breakfast:      Lunch:      

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Dinner:      Snacks:      

Do you eat: With family? Home alone? On the run? Restaurant? Fast food? Where do you commonly grocery shop?      What percentage of meals/snacks consumed are homemade?      In terms of preparing your own meals, what is your skill level in the kitchen? Please quantify on a scale of 1 (low) to 10 (high):   

How many servings of each food type do you typically consume in a day?      Fruit Fresh Frozen Canned Dried       Vegetables Cooked Raw Frozen Canned       Whole Grains Type:            Protein Type:            Dairy Type:            Fats Type:            Other Type(s):      

Do you eat or use (indicate “1” for “rarely”, “2” for “regularly”, “3” for “often”):      Aluminum pans      Artificial Sweeteners

      Candy      Cigarettes

      Refined Foods (pastries, white pasta, etc.)

      Fried Foods      Luncheon Meats

      Margarine      Microwave

      Fast Foods

Please indicate how many cups of the following you drink per day:      Tap water      Coffee      Tea      Soft drinks (diet)      Soft drinks (regular)      Fresh fruit juices      Fruit juices (prepared)      Milk      Prepared vegetable juices

      Fresh vegetable juices      Red wine      White wine      Beer      Other alcoholic beverages      Bottled or spring water      Herbal tea      Other:      

Do you currently follow a special diet? Yes No If yes, please explain:      Do you avoid certain foods? Yes No If yes, list food(s) and reason why:      

How often do you eat meat? Daily 3-5/week Once/week or less How often do you consume dairy? Daily 3-5/week Once/week or less

What’s your favourite food(s) and how often do you eat them?      Which food(s) do you crave, and how often do you eat them?      Do you experience any symptoms of meals are missed? Yes No Please explain:      Do you experience any symptoms after meals? Yes No Please explain:      

COMMENTS:      

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Nutri-System Profile (NSP) Assessment FormPlease indicate if you’re experiencing any of the symptoms or activities below by indicating: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.

General fatigue or weakness     Varicose veins    Difficulty losing weight     Feeling out of control    Frequent illness/infections     Food/chemical sensitivities    High stress lifestyle     Frequent yeast/fungus problems    Smoking     Bones break easily, osteoporosis    Drink more than 2 cups of coffee/day     Too little exercise    Bad breathe and/or body odour     Excessive mucous    Constipation     Shortness of breath climbing stairs    Bags under eyes     Tingling in lips, fingers, arms, legs    Craves sugar, bread, alcohol     Chest pains    Difficulty digesting certain foods     Very rapid or slow heart beat    Recent antibiotic use     Painful, hard or thin bowel movements    Allergies     Alternating constipation/diarrhea    Poor concentration or memory     Recurrent bladder infections    Belching or burping after meals     Female: Menopause, hot flashes    Skin/complexion problems     Female: PMS    Frequent consumption of red meat     Difficult urination    Regular use of dairy products     Swollen glands, puffy throat    Heavy alcohol consumption     Lower abdominal pain    Exposure to toxins/chemicals     Frequent need to urinate    Frequent mood swings     Joint pain    Depressed and/or irritable     Sinus inflammation/discharge    Brittle fingernails     Arthritis    Dry, brittle hair, split ends     Sudden weight gain/loss    High fat/high cholesterol diet     Headache/Migraines    Nervousness/anxiety/tension/worry     Female: Taking birth control pills    Insomnia, restless sleep     Lower back pains    Low fiber diet     Dry, flaky skin    Muscle cramps     Drink less than 6 glasses of fluid/day    Sleepy when sitting up     Water retention    Female: menstrual cramps     Low sex drive    Bronchitis/asthma//pneumonia/emphysema     Feeling heavy/bloated after meals    Cellulite     Chronic cough    Cold hands and feet    

COMMENTS:      

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PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.

THE DIGESTIVE SYSTEMExcessive gas, belching or burping after meals

    Full feeling after heavy meat meal    

Stomach bloated after eating     Heavy, tired feeling after eating    Sleepy after eating     Nausea after taking supplements    Longitudinal striations on fingernails     Acne    Eat when rushed/in a hurry     Undigested food in the stool    Bad breathe    

Stomach pain 1 hour after eating or at night     Sensation of acidity in abdominal area    Burning sensation in stomach     Heartburn, indigestion    Pain aggravated by worry/tension     Blood in stool    Hiatal hernia     Lower back pain    Gastritis, gastric ulcer     Long term aspirin use    Nausea, vomiting    

Yellow or pale fingernails     Food allergies    Skin oily on nose and forehead     Irritable, easily angered    Fats/greasy foods cause nausea, headaches     Weight gain around the abdomen    Vertical white streaks on fingernails     Yellow palms    Onions, cabbage, radishes, cucumbers cause bloating/gas

    Jaundice    

Bad breathe; bad taste in mouth     Poor concentration    Excess body odour     Difficulty losing weight    High cholesterol/high cholesterol diet     Acne, boils, rashes, psoriasis or eczema    Migraine headaches     Constipation    Discomfort underneath right ribcage    

Gall stones; history of gallstones     High cholesterol diet; high blood cholesterol levels

   

Stool appears clay-coloured, foul odoured     Severe pain in right upper abdomen    Constipation    

Severe abdominal pain     Fever    Nausea and vomiting     Alcohol addiction    Slow digestion; feel full for hours after eating

    Jaundice    

Hungry up to 3 hours after eating     Family history of diabetes    Strong cravings for sweets, starches, coffee or alcohol

    Fatigue    

Nervous/anxious feelings relieved by eating     Frequent headaches    Irritable if late for or skip a meal     Fainting spells    Overweight     Depression    Addicted to pop and/or coffee with sugar     Lose temper easily    Frequent “midnight snacks”    

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PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.

THE INTESTINAL SYSTEMExtreme fatigue     Rectal itching    Recurrent vaginal infections     Abnormal muscle aches from exercise    Frequent use of antibiotics     Excessive wax in ears    White coated tongue, oral thrush     Unexpected/unexplained weight gain    Craves sugars, bread, alcohol     Impotence    Headaches     Canker sores    Tonsillitis, recurrent strep throat     Athlete’s foot, finger/toenail fungus,

ringworm   

Itchy, watery or dry eyes     Jock itch    Skin flushes     “Brain fog”    Chronic indigestion, frequently use antacids     Irritability    Always cold, especially in extremities     Memory loss    Female: PMS     Mental confusion    Pain in pelvic area     Depression or anger for no reason    Abdominal gas and bloating     Anxiety/panic attacks    Loss of sex drive     Inability to concentrate    Cystitis, repeated bladder infection     Phobic/compulsive    Increasing food and chemical sensitivities     Lethargy    Female: Endometriosis/ ovary problems     Mood swings    Chronic diarrhea     Itchy ears, nose, anus    Hives, psoriasis, acne, skin rashes    

Forgetfulness     Pain in the back, thighs, shoulders    Slow reflexes     Numb hands    Gas and bloating     Drooling while sleeping    Unclear thinking     Damp lips at night    Loss of appetite     Dry lips during the day    Yellowish or pale face     Grind teeth while asleep    Fast heartbeat     Bedwetting    Heart pin     Lethargy; chronic fatigue    Pain in navel     Dark circles under eyes    Eating more than normal but still feeling hungry

    Cancer    

Blurry or unclear vision     Rectal itching    

THE LYMPHATIC SYSTEMExcessive sleep     Soreness on both sides of neck at shoulder    Very susceptible to infections     Feel puffiness in throat    Swollen glands: tonsils, throat, armpits     Look older than chronological age    History of cancer, MS, Parkinson’s, arthritis     Flu-like symptoms often occur    Loss of appetite     Lupus    Headaches    

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PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.

Acne, psoriasis, dermatitis, eczema     Excessive sweating, night sweats    Rapid pulse, heart irregularities     Bowel disease: IBS, IBD, Crohn’s, etc.    Frequent headaches     Joint pains or stiffness    Hay fever     Frequent night urination    Frequent cravings for certain foods     Wheezing    Periods of blurred vision     Pale face    Repeated ear trouble     Hives    Hyperactivity     Nose runs constantly    Dizzy spells     Noticeable changes in writing throughout day    Periods of confusion     Nosebleeds    Poor concentration     Bloating or gas after eating certain foods    Epilepsy     Canker sores    Muscle cramps or spasms     Dark circles under eyes    Abnormal body odour     Stuffy nose    

THE ENDOCRINE SYSTEMDistinct, lethargic tiredness or sluggishness     Hair dry, brittle, dull, lifeless    Cold hands or feet     Flaky, dry rough skin    Mercury amalgams (fillings)     Feel stiff after sitting still for some time    Gain weight easily, fail to lose on diets     Mood swings    Constipation, less than one bowel movement a day

    Usually square and wide fingernails    

Low energy in the morning     High cholesterol    Low pulse rate     Low sex drive    Low body temperature, especially bed rest    

Losing weight without trying     Insomnia    Heart races while at rest     Increased appetite    Feel warm/flushed at room temperature     Frequent bowel movements, diarrhea    Hands shake or tremble     Excessive sweating without exercising    Protruding tongue     Nervous behavior, hyperactivity    Heart palpitations        

Headaches affecting one side of head     Excessive urination    Female: Loss of menstrual function     Pain in little finger of left hand    Moody     Swelling in ankles, fingers and/or feet    Overweight from waist up     Cold hands or feet    Overweight from waist down     Pain in left side of upper neck    

Stress or emotional upset cause exhaustion     Occasional cold sweats    Dizzy/light-headed upon standing quickly from a lying or crouched position

    Tightness or lump in throat, especially when emotionally disturbed

   

Sweat excessively     High or low blood pressure    Neck and/or shoulder tension/pain     Rapid pulse    Frequent headaches     Short temper    Bow lines (depressed furrows) on fingernails     Puffy face    

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PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.

Forgetfulness, “brain fog”     Low resistance to infections, catch cold/flu easily

   

Energy crash mid-afternoon (around 2-5pm)     Difficulty falling or staying asleep    Need to snack to help energy levels and cravings

    Increased muscle soreness with similar physical activity level

   

Abdominal weight gain     Female: Worsened PMS symptoms during menstrual cycle

   

Low sex drive or lack of interest     Frequently wake up around 2-4pm, can’t fall back asleep

   

Anxiety, irritability, depression (mood swings)

    Low stamina, energy and difficulty maintaining muscle mass

   

Decreased ability to deal with stress and deadlines

    Low tolerance towards alcohol or caffeine    

Strong carbohydrate or salt cravings     Cold hands or feet/other extremities    Hair loss     Dry skin    Significant improvements in stress levels during vacation or time away from work?

   

THE STRUCTURAL-MUSCULAR/SKELETAL SYSTEMPain, swelling, stiffness in joints     Rounding of shoulders, stooping    Joint inflammation (rheumatoid arthritis)     Female: Menopause    Pain, stiffness, inflammation of spine     Pain in forearm or biceps    Facial pain     Cramps in calf muscle during sleep or

exercise   

Joints making popping sounds     Painful cramping in feet or toes    Gout     Teeth prone to decay; frequent toothaches    Ankylosing spondylitis     Malformation of bones    Bones fracture easily     Insomnia    Gradual loss of height     Muscles weak, weak grip, light objects feel

heavy   

Tooth loss; teeth “falling out”     Heart palpitations    Lack of exercise     Diet high in animal foods (meat, dairy, eggs)    

Muscle pain     Sprains; muscle strains    Muscle weakness     Muscle(s) spasm    

Muscle wasting in some part of the body     Tremors    Numbness or loss of sensation     Loss of peripheral vision    Mood swings and/or depression     Slurred speech    Blurred or double vision     Objects fall from hand, reach in wrong place    Tingling and/or numbness, especially in extremities

    Hands tremble    

Muscular stiffness     Impaired speech    Male: Impotence     Difficulty breathing    

COMMENTS:      

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Nutrient Deficiency TestPLEASE COMPLETE THE FOLLOWING TEST USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.

Excess fluid retention (edema)      Nausea or dizziness      Poor coordination      General, overall weakness      Anemia      Cataracts      Catch colds, flu, infections easily      Cuticles tear easily      Hair dull, dry, sparse, loose and falling      

Rough, dry or scaly skin      Dry, brittle hair      Eczema      Psoriasis      Poor memory      Irregular menstrual periods      

Osteoporosis      Bones break easily      Irregular heart beat      Brittle nails      Muscle cramps      Crowded teeth      Insomnia      

High blood cholesterol      Intolerance to alcohol      Diabetic or hypoglycemia      Overweight      Sugar cravings      Chronic dieter      Kidney disease      

Fatigue, extreme lack of energy      Dry hair      Thyroid problems; goiter      Overweight      Constipation      Cold hands or feet      Brittle nails      

Lack of energy or strength      Dizziness      Cravings for ice      Pale lower eyelid      Tachycardia      Spoon shaped nails      

Muscle spasms or tremors      Gall stones      Cravings for chocolate      Irregular heartbeat      Excessive body odour      

Joint pains      Bursitis, tendonitis      Prone to injuries      Weak knees      Creaking or clicking of joints      Weak muscles      

High blood pressure      Swelling of ankles      Always thirsty      Irregular heartbeat      Muscular weakness and fatigue      

Dry hair      Thin hair      Weak immunity; frequent infection      Dandruff      Cataracts      

White spots on fingernails      Acne      Male: Poor sperm production      Frequent infection      Poor dream recall      Cuts/wounds heal slowly      Loss of sense of smell or taste      Thinning hair      Red stretch marks      

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Hard little bumps around elbows      Dry or rough skin      Dry hair, acne      Poor night vision; night blindness      Susceptibility to respiratory infections      Slow light to dark adaptation      Eyes unable to produce tears      Weak tooth enamel      Dandruff      

Fatigue      Apathy, depression      Loss of knee jerk response      Irregular heartbeat      GI disorders      

Dry skin around nose and lips      Cracks/sores in corner of mouth      Bloodshot or itchy eyes      Cataracts      Eyes sensitive to light      Abnormal hair loss      Trembling painful and purplish-red tongue

     

Sore tongue      Fatigue      Loss of appetite      Skin disorders      Swelling of mouth      Smooth tongue      Mental confusion      Loss of sense of humour      Canker sores in mouth      

Anemia      Irritability or nervousness      Insomnia, poor dream recall      Sore thumbs, kidney stones      Female: acne worse during menstruation

     

Female: morning sickness during pregnancy

     

Fatigue and weakness      Lightheadedness or dizziness      Heart palpitations      Shortness of breath; chest pain      Sore, red, glazed-looking tongue      Irritability; inability to concentrate      Ringing in ears (tinnitus)      Nausea and diarrhea      Memory loss, forgetfulness      Poor coordination      

Skin disorders      Smooth and pale tongue      Loss of appetite      Pale fingernails      Irregular heartbeat      Severe depression      Mild anemia      Hair loss      

High blood pressure      High blood cholesterol      Overweight      Eczema      Bleeding ulcer      Disoriented, memory loss      Difficulty losing weight      

Paleness      Sore red tongue      Bleeding gums      Diarrhea      Insomnia      Irritability      Fatigue      

Constipation      General gastrointestinal disorders      Premature greying      Depression and irritability      Fatigue      Headache      

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Abdominal pain      Anorexia      Nausea      Burning feet      Depression and irritability      Headache      Nervousness      Purplish red tongue      

Bleeding gums      Urinary tract infections      Abnormal nose bleeds      Slow healing of wounds      General weakness      Shortness of breath      Skin bruises easily      Ruptured blood vessels in eyes      Excessive hair loss      Aching bones and joints      

Muscle weakness      Pain in ribs, spine, legs      Malformation of bones      Osteomalacia      Osteoporosis      Muscle cramps      Rickets, insomnia      Nearsightedness (myopia)      

Heart disease      Premature aging      Weakness      Irritability      Diarrhea      Poor skin condition      Brittle hair      Muscle wasting      

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