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_______________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 _______________________________________________________________________
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.