CLIENT DETAILS Name* Date* Address* Telephone* Email* Sex* : MaleFemale Age* Birthdate* Height* Feet and InchesCms Weight* KgsLbs HEALTH HISTORY 1. What medical concerns (e.g.,Pregnancy), if any, do you have at the present time?* 2. Do you have complaints about any of the following?* Cancer* : YesNo High blood pressure* : YesNo Diabetes* : YesNo Osteoporosis* : YesNo Heart disease* : YesNo Thyroid disorder* : YesNo High cholesterol* : YesNo PCOD* : YesNo Appetite* : YesNo Constipation* : YesNo Bleeding gums* : YesNo Diarrhea* : YesNo Bruising* : YesNo Edema* : YesNo Chewing or swallowing* : YesNo Indigestion* : YesNo Menstrual difficulties* : YesNo Sudden weight change* : YesNo Seeing in dim light* : YesNo Stress* : YesNo 3. Do you use tobacco in any of way?* Yes No How much? Did you recently stop smoking?* Yes No 4. Do you enjoy physical activity?* Yes No Explain 5. List any food allergies or intolerances*. DRUG HISTORY List any prescribed, over-the-counter, herbal, or vitamin/mieral supplements you take.* DIET HISTORY 1. Have you ever followed a special diet?* Yes No Explain 2. Are there certain foods that you do not eat?* 3. Do you Drink alcohol?* Yes No How Often? 4. Meal preference.* Vegan. (No Animal Products)Vegetarian. (But Eat Eggs)Vegetarian. (No Meat, Fish, Eggs or Seafood)Vegetarian (Jain)Non-Vegetarian. 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?* Improve my eating habitsImprove my activity levelLearn to manage my weightImprove my cholesyterol/triglyceride levelsOther 7. Please add any additional information you feel may be relevent to understanding your nutritional health. Accept the Disclaimer* Δ
