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 _________________________________________________

 



WHAT IS YOUR NUTRITIONAL STATUS?


Please answer the following questions with Yes, No, or Sometimes.


1) Do you skip breakfast most days? _____
2) Do you drink less than two glasses of water daily? _____
3) Do you drink more than two cups of coffee (regular or decaffeinated) daily? _____
4) Do you drink more than four cups (regular, decaffeinated, or herbal) tea daily? _____
5) Do you eat less than four servings of vegetables each day? _____
6) Do you eat less than two servings of fruit each day? _____
7) Do you eat red meat (including lamb, beef) more than three times each week? _____
8) Do you eat more than one serving white bread (including bagels, rolls, and muffins daily? _____
9) Do you drink soft drinks daily? _____ How many regular? _____ Diet? _____
10) Do you crave sweets? _____
11) Do you crave specific foods (bread, dairy products, chocolate, corn products etc.)? _____ Which? _________________________
12) Do you skip at least one meal daily? _____ Which? ______________
13) Do you eat at "Fast Food" restaurants more than once a week? _____
14) Are you stuffy or sleepy after eating certain foods, especially sweets? _____
15) Are you constipated more than once a month? _____
16) Do you have diarrhea more than once a month? _____
17) Do you have alternating constipation and diarrhea? _____
18) Do you suffer from abdominal stress or indigestion often? _____
19) Do you feel better directly after eating sweets? _____
20) Do sweets, alcohol, or coffee make you feel worse (especially fatigued)? _____
21) Are you often still hungry after eating a meal? _____
22) Do you frequently feel bloated? _____
23) Do you crave salty foods? _____
24) Do small amounts of alcohol make you feel drunk? (two beers or less, six ounces wine or one shot hard liquor)? _____
25) Do you consume a high saturated fat diet (ice cream, bacon, sausage, and/or high fat cheeses) every day? _____
26) Do you eat whole grain foods (brown rice, whole grain breads/cereals, buckwheat, wild rice, oats, rye, barley. etc.) less than once a day? _____
27) Do you eat legumes (soy products, kidney or garbanzo beans, split peas, etc.) less than one time weekly? _____
28) Do you eat fish less than two times a week? _____
29) Do you overeat at meals? _____
30) Are you a picky eater? _____
31) Are you overweight? _____ Underweight? _____ (weight _____ ht. _____)
32) Do you consume non-sugar substitutes? _____ Which ones? Splenda®/Sucralose _____ Nutrasweet®/Equal®/Aspartame _____ Sweet and Low®/Saccharin _____ Stevia Extract _____ How Much? ____________________


NOTE: Bring all dietary supplement bottles to your appointment. If you do not have the bottles, please bring the brand names and full ingredient labels.

Directions to our office