Nutritional Assessment

Full Name

Email Address

Please List your Five Major Health Concerns in Order of Importance:

Gender Gender Male Female

Birth Date:

DIET (Please check all that apply.) DIET (Please check all that apply.) Alcohol Artificial Sweeteners Candy, Desserts, Refined Sugar Carbonated Beverages Chewing Tobacco Cigarettes Cigars/pipes Caffeinated Beverages Fast Foods Fried Foods Luncheon Meats Margarine Milk Products Radiation Exposure Refined Flour/Baked Goods Vitamins & Minerals Water, distilled Water, tap Water, well Diet often for weight control

Exercise per Week: Exercise per Week: 2 or more times per week 1 time a week 2 times a month Never

Relationship: Relationship: Married Divorced Single

Divorced: Divorced: Over 2 years ago Within the last 2 years Within the last year Within the last 6 months

Work Hours Per Week: Work Hours Per Week: 60+ Hours 40 Hours 20 Hours I do not work

Medications: Medications: Antacids Anti-anxiety Medications Antibiotics Anticonvulsants Antidepressants Antifungals Aspirin/Ibuprofen Asthma Inhalers Beta Blockers Birth Control pills/ implant contraceptives Chemotherapy Cholesterol lowering medications Cortisone/steroids Diabetic medications/insulin Diuretics Estrogen or progesterone (pharmaceutical prescription) Estrogen or progesterone (natural) Heart Medications High Blood Pressure Medications Laxatives Recreational Drugs Relaxants/Sleeping Pills Testosterone (natural or prescription) Thyroid Medication Acetaminophen (Tylonel) Ulcer Medications Sildenafal Citrate (Viagra)

Please tell us more about your health: allergies, list of prescriptions, please be very specific about the daily symptoms and pains you are facing.