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 _______________________________________________________________________
Nutritional Concepts Questionnaire
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 medicate. 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/Tobacco/Health 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 ____________
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)____
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
24. Butter 0 1 2 3 4
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. Exposure to chemicals 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
Section 3: Nutritional Supplements (do not fill out if bring your supplements 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. CoEnzyme Q10 ____30mg. or less ____100mg. or greater
17. Lactobacillus Acidophilus and/or Bifidus ____________________ specify
18. Digestive Enzymes ____________________ specify
19. 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