Andrea McDonald Nutrition

R.H.N.

Lifestyle Assessment

Please answer each of the following questions. All information contained on this form will be kept strictly confidential.

Name *

First Name

Last Name

Date

MM

DD

YYYY

Age *

Sex *

Male

Female

Height *

Weight *

Email *

Phone

(###)

###

####

What is your purpose in coming here today?

What are your main health concerns/complaints? Please list in priority:

Have you experienced any major trauma in the past 5 years?

What level of stress do you feel you are experiencing at this time? Please quantify on a scale of 1 (low) to 10 (high):

What are the major causes or factors of your stress? Rate all that apply on a scale of 1 (low) to 10 (high):

Financial

Career

Personal

Marriage

Health

Family

Spiritual

Unfulfilled expectations

Other (please elaborate)

How does your stress manifest itself?

Do you use any coping mechanisms?

What do you do for exercise?

(Indicate type, frequency, time of day and duration)

On a scale of 1 (low) to 10 (high), how would you describe your energy levels?

Do you experience any lulls or highs in your energy levels throughout the day? If so, at what time of day?

How many hours on average do you sleep daily?

(include naps)

What time do you go to sleep?

Hour

Minute

Second

Awaken?

Hour

Minute

Second

Do you have trouble:

Falling asleep?

Staying asleep?

Do you awaken feeling rested?

Yes

No

Do you snore?

Yes

No

What is your occupation?

Do you enjoy your work?

Yes

No

Sometimes

How many hours each day do you work?

At what times do you start and end work?

Hour

Minute

Second

Do you work:

Shifts?

Regular schedule?

Do you smoke?

Yes

No

If yes, how much and for how long?

If no, does anyone in your household or workplace smoke?

Yes

No

Do you wish to:

Lose weight

Gain weight

How much?

By when do you wish to reach your goal weight?

MM

DD

YYYY

What is your main motivation to change your weight?

How many hours do you spend daily, on average, driving?

How many hours do you spend daily, on average, watching television?

How many hours do you spend daily, on average, reading?

How many hours do you spend daily, on average, in front of a computer?

What are your interests and hobbies?

Do you vacation regularly?

Yes

No

When was your last vacation?

Do you actively participate in any spiritual discipline (church, religious group, meditation, etc.)?

Yes

No

MEDICAL HISTORY

Are you currently taking any medication?

Yes

No

List all medications and the reason(s) for each:

Do you take: birth control pills?

Yes

No

Have you taken antibiotics over the past five years?

Yes

No

Please list any vitamins, minerals, herbal or homeopathic remedies you are currently taking and the amounts/dosages:

Do you have any allergies or sensitivities?

Yes

No

If so, please list:

Do you have anaphylaxis (life-threatening allergy)?

Yes

No

If so, please describe:

Do you have any silver-mercury fillings?

Yes

No

Have you ever been diagnosed with an illness?

Yes

No

If so, please explain:

Have you ever been hospitalized?

Yes

No

If yes, for what reason?

Have you had surgery to remove your:

gall bladder?

tonsils?

appendix?

How often do you have a bowel movement?

Do you strain to have a bowel movement?

Yes

No

Occasionally

Related to particular food or circumstances?

Do you have loose bowel movements?

Yes

No

Occasionally

Related to particular food or circumstances?

Is there undigested food in your stools?

Yes

No

Occasionally

Do you use recreational drugs?

Yes

No

If yes, how often and what type?

Have you ever been treated for drug and/or alcohol dependency?

Yes

No

FAMILY HISTORY

Do you have a family history of Allergies?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Alcoholism?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Arthritis?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Asthma?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Autoimmune Disease?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Cancer?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Diabetes?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Drug Abuse?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Gall Bladder Issues?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Heart Disease?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Hypertension?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Intestinal Disease?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Kidney Dysfunction?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Mental Illness?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Osteoporosis?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Skin conditions?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Do you have a family history of Ulcers?

Use “F” for father, “M” for mother, “S” sibling, “G” for grandparent, “O” for other(s), "N" for no.

Other diseases (please list):

Have you experienced fungal infections (e.g. jock itch, athlete’s foot)?

Yes

No

If yes, please describe:

Have you experienced a decline in sexual interest?

Yes

No

If yes, please describe:

Have you had kidney or gall stones?

Yes

No

If yes, please describe:

FEMALES

Are you or could you be pregnant?

Yes

No

Have you noticed any changes in menses, for example the frequency, duration, flow, clotting, or other changes?

Yes

No

If yes, please specify:

Do you suffer from PMS symptoms?

Yes

No

If yes, please specify:

Are you pre-menopausal?

Yes

No

Are you 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 (e.g. frequent urination, discomfort during urination)?

Yes

No

If yes, please describe:

DIETARY HABITS

How many times a day do you eat main meals?

What times of day?

How many times a day do you eat snacks?

What times of day?

Do you eat meals:

with family

home alone

on the run

fast food

Do you feel there are restrictions to your diet due to preferences of others such as family, roommates, etc?

Yes

No

If yes, please explain:

How many 1⁄2 cup servings of fresh fruit do you typically eat in a day:

How many 1⁄2 cup servings of dried fruit do you typically eat in a day:

How many 1⁄2 cup servings of canned fruit do you typically eat in a day:

How many 1⁄2 cup servings of cooked vegetables do you typically eat in a day:

How many 1⁄2 cup servings of raw vegetables do you typically eat in a day:

How many 1⁄2 cup servings of whole grains do you typically eat in a day:

How many 1⁄2 cup servings of protein do you typically eat in a day:

What types of protein?

How many 1⁄2 cup servings of dairy products do you typically eat in a day:

What types of dairy products?

How many 1⁄2 cup servings of other foods do you typically eat in a day:

What types?

Provide an example of your typical breakfast:

Provide an example of your typical lunch:

Provide an example of your typical dinner:

Provide an example of your typical snacks:

Do you use aluminum pans?

indicate “1” for “rarely”, “2” for “regularly”,”3” for “often”

Do you use a microwave?

indicate “1” for “rarely”, “2” for “regularly”,”3” for “often”

Do you eat luncheon meats?

indicate “1” for “rarely”, “2” for “regularly”,”3” for “often”

Do you use artificial sweeteners (Nutra Sweet, aspartame, Splenda)?

indicate “1” for “rarely”, “2” for “regularly”,”3” for “often”

Do you eat refined foods (pastries, white bread/pasta/rice, etc.)?

indicate “1” for “rarely”, “2” for “regularly”,”3” for “often”

Do you eat margarine?

indicate “1” for “rarely”, “2” for “regularly”,”3” for “often”

Do you eat fried foods?

indicate “1” for “rarely”, “2” for “regularly”,”3” for “often”

Do you use cigarettes?

indicate “1” for “rarely”, “2” for “regularly”,”3” for “often”

Do you eat candy?

indicate “1” for “rarely”, “2” for “regularly”,”3” for “often”

Do you eat fast foods?

indicate “1” for “rarely”, “2” for “regularly”,”3” for “often”

Please indicate how many cups of tap water you drink per day:

Please indicate how many cups of coffee you drink per day:

Please indicate how many cups of tea you drink per day:

Please indicate how many cups of soft drinks (diet ) you drink per day:

Please indicate how many cups of soft drinks (regular) you drink per day:

Please indicate how many cups of fresh fruit juices you drink per day:

Please indicate how many cups of fruit juices (prepared) you drink per day:

Please indicate how many cups of milk (1%, 2%, or whole) you drink per day:

Please indicate how many cups of milk (skim) you drink per day:

Please indicate how many cups of prepared vegetable juices you drink per day:

Please indicate how many cups of fresh vegetable juices you drink per day:

Please indicate how many cups of red wine you drink per day:

Please indicate how many cups of white wine you drink per day:

Please indicate how many cups of beer you drink per day:

Please indicate how many cups of other alcoholic beverages you drink per day:

Please indicate how many cups of bottled or spring water you drink per day:

Please indicate how many cups of herbal tea you drink per day:

Please indicate how many cups of other beverages do you drink per day:

Are you a:

meat eater?

vegetarian?

vegan?

How often do you eat meat?

daily

3-5/week

once/week or less

How often do you consume dairy products?

daily

3-5/week

once/week or less

What are your favourite foods?

How often do you eat them?

Which food(s) do you crave, and how often do you eat them?

Do you avoid certain foods?

Yes

No

If so, why?

Do you experience any symptoms if meals are missed? Explain:

Do you experience any symptoms after meals? Explain:

Additional comments:

Signature *

Today's Date *

MM

DD

YYYY

All information contained on this form will be kept strictly confidential.

Thank you!

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