Welcome to Nutritional Concepts!


This is your new client written evaluation packet. 
Please mail, fax, or email the following completed 
materials with a check payable to Nutritional Concepts 
or VISA/MC (you may phone in your credit card with 
expiration date or write it below) for $150.00.

Checklist
Client Info Sheet
Nutritional History & Recommendations Sheet
List of Medications and Dietary Supplements
Completed questionnaire
Three day food diary
Bloodwork (less than six months old) with blood type optional
$150.00 check or VISA/MC ________________________________________________ exp ________



Bloodwork Requirements (optional):
(most clients do through their physicians for insurance reasons)
*Please do not bring labs taken before or after a surgical procedure, 
if you  had an infection (i.e., cold/flu)
, or for insurance purposes.

CBC (including basophils and eosinophils)
CHEM SCREEN with HDL/LDL cholesterol differential
CO2 (as bicarbonate)
Thyroid
ESR (Sed Rate)
Ferritin
CRP (C-Reactive Protein)
Simple Urinalysis
Blood Type (if you do not know)
Vitamin D 25 Hydroxy [25(OH) D (optional, but recommended)]
Fasting (10PM evening prior; water OK)

No dietary supplements 24 hours prior
If on antihistamines, antibiotics or cortisone, please call our office.

If you are LOCAL and not doing through physician, our lab 
affiliation is Northern Illinois Clinical Labs (NICL) in Northbrook.
Cost: $169.00 or $189.00 (if you need blood type); $54 for vitamin D test
We do not bill to insurance. Although, you will 
receive a receipt with diagnosis if you wish to submit.

Come to our office at Professional Plaza, 1535 Lake Cook Road, 
Suite 204 in Northbrook to pick up requisition and pay for lab 
services (the lab requires 3 business days to process bloodwork).
Our office hours are M-SAT 9AM-5PM.  Directions to our office
NICL lab office hours are M-F 9:30AM-3:30PM. No appointment needed.
NICL has other lab locations.


After receiving your welcome packet, Bonnie Minsky will take
10-14 days to complete her analysis. She will then mail, fax, or 
email  your nutritional evaluation in memo format complete 
with applicable materials. If you have questions, or wish to
fine-tune your evaluation, we recommend waiting several few 
weeks and attempt to implement her suggestions before 
making a thirty minute in-office or phone appointment.

 



CLIENT INFORMATION SHEET

Welcome to Nutritional Concepts. None of our services, nutritional counseling, 
chiropractic and massage therapy, should be substituted for appropriate 
medical consultation or treatment.

Our goal is to provide you with the most qualified and professional health care 
services. We intend to refer when necessary, to educate the community, and to 
educate and work with the entire family so that everyone may have a healthier lifestyle.
 

NAME ______________________________________________  DATE_______________

LEGAL GUARDIAN’S NAME (If you are under 18) ______ __________________________

BIRTHDATE ____________ 
AGE _____   OCCUPATION ______ ____________________

ADDRESS ________________________________________________________________

CITY ______________________________ STATE _______ ZIP CODE _______________

FAX ____________________  E-MAIL __________________________________________

HOME ____________________ WORK ___________________ CELL _________________

PHYSICIAN ________________________________________________________________

HOW DID YOU HEAR ABOUT US? _____________________________________________

LIST CURRENT HEALTH CONCERNS/SYMPTOMS:

 


LIST ALL SURGERIES:

 


LIST ALL CURRENT MEDICATIONS INCLUDING ASPIRIN:




PAYMENT DUE UPON RECEIPT OF SERVICES.
PLEASE HONOR OUR 24 HOUR CANCELLATION POLICY.



NUTRITIONAL HISTORY/RECOMMENDATIONS

Client Name ______________________________________ Date (appt.) ________________  

Address _____________________________________________ Phone _________________

Current Nutritional and Health Problems:

___________________________________________________________________________

___________________________________________________________________________

*PLEASE DO NOT WRITE BELOW*    *PLEASE DO NOT WRITE BELOW*

STATUS

Ht ______Wt _______   Edema:  Yes ____ No ____    Pallor ________  Blood Type____

Complexion _____________________  Muscle Tone _____________________________ _____

SUSPECTED NUTRITIONAL IMBALANCES

Vitamins _____________________________________________________________________  

Minerals______________________________________________________________________

Acid/Alkaline Balance ___________________________________________________________

Food Allergies/Sensitivities _______________________________________________________

Other Allergies/Sensitivities _______________________________________________________

Digestion:  Good____ O.K.____ Needs Improvement _____

Esophagus ____________________________________________________________________

Stomach _______________________Intestines ____________________ Colon _____________

DIETARY CONSIDERATIONS

Calories:  Too many ___ Not enough ___ Recommendation for Daily Caloric Intake

 _____________________________________________________________________________

Fiber:  Good ___ Needs more ___ How much daily? 

______________________________________________________________________________

Fruit servings:  Good ___ Not enough ___ # of servings ___ Sources 

______________________________________________________________________________

Vegetable servings:  Good ___ Needs more ___ # of servings ___ 

Sources_______________________________________________________________________

Protein servings:  Good ___ Not enough ___ Too much ___ # of servings ____

Sources _______________________________________________________________________

Calcium:  _____ mg. needed daily    Sources - Dairy ________Non-dairy __________________

Fat:  Good ______ Too much ______ Not enough ______  Recommendations - _____gm. daily      

______________# servings daily    % of total diet ________  

Sources _______________________________________________________________________

Sodium:  Good _____ Too much _____ Not enough _____ Recommendations - _____mg. daily

Non-caloric Sweeteners: _____Equal _____Saccharin _____ Splenda  _____ 
Stevia _____ # servings daily

Sweeteners:  Good _____ Too much _____ not enough _____ 

Sources _______________________________________________________________________

Total Carbohydrates:  Good _____ Too much _____ Not enough _____ 

Sources _______________________________________________________________________

Bread/Grain Carbohydrates:  Good _____ Too much _____ Not enough _____ 

Sources _______________________________________________________________________

Food Plan ___ Follow-up __________________________________________________________ 

Recommendation for Other Services _________________________________________________

 




Three Day Food Diary

DAY ONE

Foods      

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

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Drinks

_________________________________________

_________________________________________

_________________________________________

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DAY TWO

Foods

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

Drinks

_________________________________________

_________________________________________

_________________________________________

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DAY THREE

Foods

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

Drinks

_________________________________________

_________________________________________

_________________________________________

_________________________________________

 



NCI Wellness Evaluation

Please complete the questionnaire to the best of your ability.
The more information we have, the better we can serve you.

Information Section:

Full Name ____________________________ Date ___/____/______

Sex___ Weight ____ Height ____ Age____

Frame Size- S__ M__ L__     BLOOD TYPE ____

e-mail address___________________________________________________

Part A: Lifestyle Risks*

Instructions- Circle the number that best describes usage

0= Never
1= Have had in the past, but not recently
2= occasionally (1 x weekly or less)
3= regularly (2-4 x weekly)
4= daily (5-7 x weekly)

*Leave blank any items that you choose not to answer.

Section 1: Medication/Drug Consumption

1. Antacids 0 1 2 3 4

specify ______________________

2. Antibiotics/Antifungals 0 1 2 3 4

3. Antidepressants 0 1 2 3 4

4. Anti-diabetic oral medication 0 1 2 3 4

5. Insulin (injectable) 0 1 2 3 4

6. Aspirin 0 1 2 3 4

7. Antihistamines 0 1 2 3 4

8. Non-aspirin (ie: Tylenol) 0 1 2 3 4

9. Chemotherapy 0 1 2 3 4

10. Radiation 0 1 2 3 4

11. Cortisone 0 1 2 3 4

12. Non steroidal anti-inflamm. 0 1 2 3 4

13. Heart medication 0 1 2 3 4

14. High blood pressure medications 0 1 2 3 4

15. Hormones 0 1 2 3 4

specify ______________________

16. Oral contraceptives 0 1 2 3 4

17. Laxatives 0 1 2 3 4

18. Muscle Relaxant 0 1 2 3 4

19. Sleeping pills 0 1 2 3 4

20. Diuretics 0 1 2 3 4

21. Thyroid medication 0 1 2 3 4

22. Ulcer medication 0 1 2 3 4

specify ______________________

23. Recreational Drugs 0 1 2 3 4

24. Other 0 1 2 3 4

specify ______________________

Section 2: Food/Drink Habits

1. Alcohol (wine/beer) 0 1 2 3 4

specify # of drinks __________

2. Alcohol (hard liquor) 0 1 2 3 4

specify # of drinks __________

3. Coffee 0 1 2 3 4

specify # of cups ____________

decaf ____ regular ____

4. Milk 0 1 2 3 4

specify # of 8oz. glasses __________
skim ____ lowfat ____ regular ____

5. Vegetables 0 1 2 3 4

specify # of servings ____________

6. Fruit 0 1 2 3 4

specify # of servings ____________

7. Fruit juice 0 1 2 3 4

specify # of servings ____________

8. Red meat 0 1 2 3 4

specify # of 2oz. servings ____________

9. Fish 0 1 2 3 4

specify # of 3oz. servings ____________

specify types of fish ________________

10. Bread (including bagels, rolls) 0 1 2 3 4

specify # of servings ____________

11. Poultry 0 1 2 3 4

specify # of 2oz. servings ____________

12. Soft Drinks 0 1 2 3 4
specify # of 12oz. glasses ____________
Regular ______ Diet _______

13. Tea 0 1 2 3 4
specify # of 8oz. cups ____________
decaf ____ regular ___

14. Water  0 1 2 3 4
specify # of 8oz. glasses ____________
tap ____ distilled ___ mineral____

15. Hard Candy 0 1 2 3 4

16. High sugar foods (cakes, cookies, pies, added sugar, etc.) 0 1 2 3 4

17. Non caloric sweeteners 0 1 2 3 4
Aspartame (Nutrasweet)____
Sucralose (Splenda)____
Saccharin (Sweet & Low) ____
Other (please specify) ____

18. Luncheon meats (i.e.bologna, salami, smoked meats, hot dogs) 0 1 2 3 4

19. Salty foods or added salt to prepared foods w/o tasting first 0 1 2 3 4

20. Fried foods 0 1 2 3 4

21. "Fast Foods" (Wendy’s, McDonald’s, Burger King, etc.) 0 1 2 3 4

22. Chocolate 0 1 2 3 4

23. Margarine 0 1 2 3 4
with transfat ___  no transfat ___

24. Butter 0 1 2 3 4

Section
3: Lifestyle Habits/Environmental Exposure

25. Chewing Tobacco 0 1 2 3 4

26. Cigarettes 0 1 2 3 4

27. Cigars 0 1 2 3 4

28. Exposure to 2nd hand smoke 0 1 2 3 4

29. Food Chemicals (preservatives, artificial colors/flavors, MSG)  0 1 2 3 4

30. Dieting to lose weight 0 1 2 3 4

31. Exercise 0 1 2 3 4

32. If you exercise 5-7x weekly 0 1 2 3 4
(0=15 min or less; 1=20-30min; 2=35-60min; 3=65-90min; 4=90+min)

33. Exposure to excess stress 0 1 2 3 4

34. Home Water Filtration
Bath     ___ yes ___ no
Drink    ___ yes ___ no

35. Cosmetics use
Natural   ___   Regular ___

36. Bath & Body product use
Natural   ___   Regular ___

37. Household product use
Natural   ___   Regular ___

38. Insecticide use
Natural   ___   Regular ___

39. Lawn Care Chemical use
Natural   ___   Regular ___

40. Dry Cleaned Clothing
Natural   ___   Regular ___

41. Is your home mold-free?
___ yes   ___ no   ___ not sure

42. Live 100ft. or less from power lines?
___ yes   ___ no   ___ not sure

43. Do you grill more than 1x weekly?
___ yes   ___ no

44. Do you use air fresheners?
___ yes   ___ no

45. Cell phone use
___ minutes/day    OR   ___ hours/day

46. Computer use
___ minutes/day    OR   ___ hours/day

47. Give a description of your vocation/career and, if applicable, how it is harming your health and/or contributing to your symptoms:

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Section 4: Nutritional Supplements (PLEASE bring supplement bottles to appt.)

Instructions- Check all items you consume on a daily basis

1. Vitamin A ____5000-10,000 i.u. ____10,000 i.u. or greater

2. Beta Carotene ____10,000 i.u. or greater

3. Vitamin C ____500mg or less ____1000mg  ____1500mg or greater

4. Vitamin E ____100-400i.u. ____1000i.u. or greater

5. Vit. B-3 (Niacinamide) ____50 mg. or greater

6. Vitamin B-6 ____50 mg. or greater

7. Vitamin B-12 ____50 mcg. or greater

8. Folic Acid ____400 mcg. or greater

9. Vitamin D ____400i.u. ____800i.u. or greater

10. Calcium ____500mg. or less ____1500mg. or greater

11. Magnesium ____250-400mg. ____1000mg. or greater

12. Zinc ____15mg. or less ____60mg. or greater

13. Chromium ____100mcg. or less ____450mcg. or greater

14. Iron ____15-18mg. ____19mg. or greater

15. Selenium ____100mcg. or less ____500mcg. or greater

16. Co-Enzyme Q10 ____30mg. or less ____100mg. or greater

17. Lactobacillus Acidophilus and/or Bifidus ____________________ specify

18. Digestive Enzymes ____________________ specify

19. Omega-3 (EPA/DHA) ___ Less than 1000 mg.   ___ More than 1000 mg.

20. Other: _________________________________________ specify

Part B-Family Health History Questionnaire*

Instructions- Circle the number that applies to the question.
Please leave blank any questions you choose to keep confidential.

0= Does not apply
1= Myself
2= Mother
3= Father
4= Grandparents

*Leave blank any items that you choose not to answer.

1. Do you have a history of headaches? 0 1 2 3 4

2. Do you have a history of cancer? 0 1 2 3 4

3. Do you have a history of diabetes? 0 1 2 3 4

4. Do you have a history of heart disease? 0 1 2 3 4

5. Do you have a history of arthritis? 0 1 2 3 4

6. Do you have a history of hepatitis? 0 1 2 3 4

7. Do you have a history of depression? 0 1 2 3 4

8. Do you have a history of alcoholism? 0 1 2 3 4

9. Do you have a history of HIV? 0 1 2 3 4

10. Do you have a history of drug abuse? 0 1 2 3 4

11. Do you have a history of smoking addiction? 0 1 2 3 4

12. Do you have a history of osteoporosis? 0 1 2 3 4

Part C-Health Related Symptoms*

Instructions- Circle the number that most accurately describes your symptoms.

0= I don’t have symptom.
1= The symptom is mild or occurs rarely.
2= The symptom is moderate or occasional.
3= The symptom is severe or often.

*Leave blank any items that you choose not to answer.

1. Watery or itchy eyes 0 1 2 3

2. Swollen, red, or sticky eyeballs 0 1 2 3

3. Excessive Eye debris 0 1 2 3

4. Itchy ears 0 1 2 3

5. Fluid in ears 0 1 2 3

6. Frequent ear infections 0 1 2 3

7. Ringing in ears 0 1 2 3

8. Hearing loss 0 1 2 3

9. Need to clear throat 0 1 2 3

10. Mucus in throat 0 1 2 3

11. Hoarseness 0 1 2 3

12. Irritated or sore throat 0 1 2 3

13. Swollen gums or lips 0 1 2 3

14. Canker sores 0 1 2 3

15. Coughing 0 1 2 3

16. Stuffy nose 0 1 2 3

17. Sinus problems 0 1 2 3

18. Hay fever 0 1 2 3

19. Sneezing attacks 0 1 2 3

20. Hives or rashes 0 1 2 3

21. Nausea 0 1 2 3

22. Water retention 0 1 2 3

23. Specific food cravings 0 1 2 3

24. Pain or aches in joints 0 1 2 3

25. Pain or aches in muscles 0 1 2 3

26. Arthritis 0 1 2 3

27. Stiffness 0 1 2 3

28. Limitation in range of motion 0 1 2 3

29. Muscle fatigue 0 1 2 3

30. Whole body fatigue 0 1 2 3

31. Heartburn 0 1 2 3

32. Rapid or pounding heart 0 1 2 3

33. Irregular or skipped heartbeat 0 1 2 3

34. Asthma 0 1 2 3

35. Bronchitis 0 1 2 3

36. Shortness of breath 0 1 2 3

37. Breathing difficulty 0 1 2 3

38. Frequent or urgent urination 0 1 2 3

39. Hyperactivity 0 1 2 3

40. Attention deficit disorder 0 1 2 3

41. Anxiety 0 1 2 3

42. Nervousness 0 1 2 3

43. Irritability 0 1 2 3

44. Mood swings 0 1 2 3

45. Headaches 0 1 2 3

46. Faintness 0 1 2 3

47. Insomnia 0 1 2 3

48. Dizziness 0 1 2 3

49. Vertigo 0 1 2 3

50. Erratic vision (not corrected by glassesor contact lenses) 0 1 2 3

51. Anger or aggressiveness 0 1 2 3

52. Chest pain 0 1 2 3

53. Binge or compulsive eating 0 1 2 3

54. Excessive overweight 0 1 2 3

55. Extremely underweight 0 1 2 3

56. Apathy, lethargy 0 1 2 3

57. Poor memory 0 1 2 3

58. Poor concentration 0 1 2 3

59. Poor coordination 0 1 2 3

60. Difficulty in making decisions 0 1 2 3

61. Slurred speech 0 1 2 3

62. Stuttering or stammering 0 1 2 3

63. Depression for no apparent reason 0 1 2 3

64. Flushes or hot flashes 0 1 2 3

65. Acne 0 1 2 3

66. Hair loss 0 1 2 3

67. Excessive sweating 0 1 2 3

68. Frequent colds or flu 0 1 2 3

69. Surgery of any kind in last 6 months 0 1 2 3

70. Enlarged prostate 0 1 2 3

71. Alcohol binges or being drunk 0 1 2 3

72. Dark circles or bags under eyes 0 1 2 3

73. Yellow or Grey skin 0 1 2 3

74. Genital itch or discharge 0 1 2 3

75. Food poisoning (includes salmonella shigella, giardia, e coli) 0 1 2 3

76. Diarrhea 0 1 2 3

77. Constipation 0 1 2 3

78. Belching 0 1 2 3

79. Gas or bloating 0 1 2 3

80. Abdominal or Intestinal discomfort from 1- 4 hours after eating 0 1 2 3

81. Iron deficiency anemia 0 1 2 3

82. Very pale skin with dark circles or or sunken eyes 0 1 2 3

83. Digestive disorders 0 1 2 3

84. Craving for unusual foods or non- food items 0 1 2 3

85. Fatigue, apathy, or lethargy with poor concentration or comprehension 0 1 2 3

Notes: Anything else you want to add that does not appear in the information provided.

__________________________________________________________________

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END