Adobe FormsCentral

PERSONAL & CONTACT INFORMATION
First name *
Last name *
Date of Birth *

Month Day Year
Date
Age
Marital Status
Gender:
Number of Children
Occupation
City
Street Address
Postal Code
Phone number to be contacted at: *
E-Mail *
GENERAL HEALTH HISTORY
Have you ever been diagnosed with an illness? Explain:
Please list any medications you are taking and the reason for the medication
Please list any vitamins or supplements that you are taking
Do you have any known allergies or suspected food intolerances?

Yes No
Have you ever been treated for:

High blood pressure High cholesterol Thyroid Diabetes None
List all:

	1	2	3	4	5
I am happy with my current weight
I regularly track my personal health measures such as weight and blood pressure
I am happy with my body composition (muscle mass vs fat mass)
I get at least 30 minutes of moderate aerobic activity 3 to 4 days per week
I participate in strength training exercises at least twice per week
I am satisfied with my level of energy
I am able to complete my activities of daily living with little or no difficulty
I stretch 2 to 3 times per week or after work-outs
I feel I have a strong core with no or very little back pain
I am happy with my current level of fitness

	1	2	3	4	5
I think my diet is well balanced
I eat at least 8-10 servings of fruits and/or vegetables a day
I drink 8-10 cups of water a day
I am aware that certain foods affect the way I feel
I pay attention to the amount of food I eat
I avoid high sugar content foods
I avoid highly processed/fast foods
We mostly prepare our own food at home
I don't suffer from heartburn
My digestive system is regular (at least 1 bowel movement per day)
I don't suffer a loss of energy in the middle of the afternoon
I eat when I am stressed
I eat for emotional reasons

	1	2	3	4	5
I manage stress well
I feel in control of my life (work and family)
I have the support of my family and friends to lead a healthy lifestyle
I get 7-8 hours of sleep a night
I wake up feeling rested and refreshed
I am interested in learning more about health and wellness
I am a happy and positive person
I participate in mind-body activities regularly (meditation, Tai-chi or yoga)
I make time for myself
I feel positive about my future

Thank you for filling out the Registered Holistic Nutrition Health Questionnaire. We look forward to helping you with your Health!