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Name:
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Height:
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Weight:
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Sex |
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Please list the main reasons why you seek a Health and
Nutritional Consultation
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Have you noticed
any significant increase in your appetite over the last 5 years?
If so, please describe briefly:
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How difficult
is it for you to avoid over eating? (0=none 10=maximum):
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Do you have any
cravings? If so, for what? :
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How difficult
is it for you to control your cravings for certain foods?
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Please indicate
the level of your stress on the scale below:
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On a scale of
1 to 6, where 1 means no resistance to your eating desires (eating whatever
you want, whenever you want it) and 6 means total restraint (always limiting
food intake and never "giving in"), what number would you give yourself?
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How often do
you have a bowel movement?
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Do you feel bloated
after almost every meal?
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If you have bloating,
what usually makes it worse?
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Approximately
what times of the day does the bloating get worse?
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Is your bloating
usually worse before or during periods? (females only)
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Which part of
your abdomen becomes distended immediately after a heavy meal
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If you have been
suffering from mental/emotional stress, please indicate briefly:
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Are you regularly
practicing some form of breathing exercise?
If so, please describe the
type of breathing exercise and
how long
you have been doing it
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Do you do any
exercise on a regular basis? If so, describe
what exercise,
duration, how often, for how long:
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If you are interested
in weight loss, please indicate the reason(s) why you want to lose weight:
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If you have a
particular part of the body you would like to shape up please indicate:
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Have you ever tried any weight loss programs
before? If so, describe
what kind, when,
with what result:
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Please list the
current and previous treatment (conventional and alternative) information
for your health concern(s). List
practitioner's
name, treatment, result:
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What type of
water do you drink?
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Do you have a
water filtration system in your house or office? If so, please describe:
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Do you regularly
take vitamins, mineral, herbal or nutritional suplements:
If so, please describe:
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Using the table
below, please describe your typical diet for the past 6 months
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General Questionnaire