Client Assessment


CLIENT DETAILS







Sex* :








HEALTH HISTORY

2. Indicate if you have had blood relatives with any of the following problems:

Cancer* :

High blood pressure* :

Diabetes* :

Osteoporosis* :

Heart disease* :

Thyroid disorder* :

High cholesterol* :

PCOD* :

3. Do you have complaints about any of the following?

Appetite* :

Constipation* :

Bleeding gums* :

Diarrhea* :

Bruising* :

Edema* :

Chewing or swallowing* :

Indigestion* :

Menstrual difficulties* :

Sudden weight change* :

Seeing in dim light* :

Stress* :

 
 
 

DRUG HISTORY

DIET HISTORY

 
 

4. Meal preference.*

5. Dietary Recall*

Meals Time Food Consumed
Early Morning*
Breakfast*
Mid Morning*
Lunch*
Snacks*
Mid Evening*
Dinner*
After-Dinner*

6. What change would you like to make?*

  Accept the Disclaimer*


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