Académique Documents
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Basic Information
Please complete all information & questions:
Todays Date_________________
Name______________________________________ Cell ________________________
Street Address _______________________________ Phone/Home_________________
City____________State_____ Zip________Phone/Work_____________Fax_________
Date of Birth _________ Age_______ Race______ Weight (stripped)______ Ht ______
Male(waist measurement)_______ Female(hip measurement)_______
Blood Pressure ___________ Blood Type (A,B,AB,O)______________________
Social Security Number________________ E-mail______________________
Referred by______________________________________________________________
Occupation: Current _______________________ Past____________________________
Please make a copy of all the information that you return to Lifestyle Fitness & Nutrition
So that you can follow along during your consultation
& have for your records.
INSTRUCTIONS:
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5.
GENERAL INFORMATION
Do you consider your general health to be?
Excellent
Good
Fair
Poor
Excellent
Good
Fair
Poor
The health consult will address your total health picture; however, we would like to know your top 3 health concerns,
symptoms and/or goals: Attach another sheet if more space is needed.
1._____________________________________________________________________________________________
2. _____________________________________________________________________________________________
3. _____________________________________________________________________________________________
Do you prefer gradual or comprehensive changes to diet and lifestyle?_______________________________
Are you currently under a physicians care? ___Yes ___No
If yes, why?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Yes
No
Yes
No
Name
_______________________
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Dose
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Reason
____________________________________________________________
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Yes No
Heart Disease/
Arteriosclerosis
High/Low
Yes No
Cancer:
Yes No
Rheumatoid Arthritis
Yes No
Nervousness
Radiation Treatments
Osteoarthritis
Hallucinations
Chemotherapy
Joint Pain/Swelling
Autism
Type_____________
Blood Pressure
Chest Pain
Treatment
High Cholesterol
Tumors/ Growths
Bone Fractures
Antidepressants
High Triglyceride
Stomach/
Gout
Psychiatric Care
Intestinal Disorder
Blood Disease
Bowel Disorder
Cortisone/Steroids
Suicidal
Stroke
Iron Overload
Ulcers
Depression
Chronic Fatigue
Sinus Headaches
Hemochromatosis
Bruise Easily
Frequent Diarrhea
Syndrome
Varicose Veins
Constipation
Fibromyalgia
Alzheimers Disease
Anemia
Anorexia
Unexplained Fever
Dementia
Bleeding Disorders/
Bulimia
Swollen
Difficulty
Hemophilia
Glands/Nodes
Venereal Disease
Concentrating
Leukemia
Diabetes:
Hypoglycemia
AIDS
Osteoporosis
Excessive Thirst
HIV Positive
Allergies
Breathing Problem
Night Sweats
Blood Transfusion
Hives/Rashes
Lung Disease
Liver Disease
Herpes
Excessive
Snoring
Hepatitis
Bleeding Gums
Cold/Clammy Skin
Frequent Cough
Yellow Jaundice
Periodontal (Gum)
Speech Disorders
Type____________
Allergies (ToMedicines)Type____________
(To Pollen/Dust)
Shortness of Breath
Perspiration
Disease
Sinus Trouble
Kidney Problems
Cold Sores/
Drug Addiction
Fever Blisters
Asthma
Renal Dialysis
Mouth Ulcers
ALS/
Lou Gehrigs Disease
Emphysema
Gall Bladder
Disease/Stones
Tuberculosis
Thyroid Disease
Frequent Tooth
Epilepsy/Seizures
Decay
Bad Breath
Convulsions
(Halitosis)
Hemorrhoids
Parathyroid Disease
Dentures
Vision Problems
Overweight
Pregnant/Uncertain
Calculus (Tartar)
Glaucoma
(currently)
on Teeth
Underweight
Nursing
Fainting/Dizziness
Ear Problems
Prostate Problems
Numbness
Sleep Disorders
Chronic Migraines/or
Headaches
If any blood relatives (e.g., father, mother, grandparents, brothers, sisters, etc.) have had any of the health
issues listed on the previous page, please explain.
Yes
No
___
___ Father ______________________________________________________________________________
___
___ Mother ______________________________________________________________________________
___
___ Grandparents ________________________________________________________________________
___
___ Siblings_____________________________________________________________________________
___
___ Other ______________________________________________________________________________
DIET
Yes No Have you experienced any weight changes in the last 6 months?
Gain ___lbs. Loss ___ lbs.
Yes No
______________________________________________________________________________________
____________________________________________________________________________________
If you are dieting, does your diet have a name? _______________________________________________
Was it recommended by someone? ________________________________________________________
Yes No
Do you maintain a healthy diet (i.e., protein, fresh fruits, grains, vegetables, & cultured
dairy)?
Explain_____________________________________________________
__________________________________________________________________________
FOODS AND NUTRITION
& snacks.
Yes No
Yes No
Yes No
Yes No
Yes No
Do you eat processed/refined carbohydrates (e.g., pasta, white bread, potatoes, snacks,
desserts, sugar, candy, artificial sweeteners, MSG, etc.)? List which ones & how often:
_____________________________________________________________________________________
_______________________________________________________________________________
Which of the following foods do you prefer to eat the most?
____ Meat, eggs, beans
____ Vegetables
____ Fruits
____ Breads, grains, cereals
Which of the following foods do you regularly eat and how often?
FOODS
SERVINGS (How Often)
SERVINGS (How Much) (Indicate portion size if you dont know ounces)
High Protein Foods
Per Day
Per Week
Ounces
Small
Medium
Large
Beef
___________ ___________ ___________ ___________ ___________ ___________
Pork
___________ ___________ ___________ ___________ ___________ ___________
Poultry
___________ ___________ ___________ ___________ ___________ ___________
Fish
___________ ___________ ___________ ___________ ___________ ___________
Cheese
___________ ___________ ___________ ___________ ___________ ___________
Eggs
___________ ___________ ___________ ___________ ___________ ___________
Nuts
___________ ___________ ___________ ___________ ___________ ___________
Whole grains
___________ ___________ ___________ ___________ ___________ ___________
Beans/Peas
___________ ___________ ___________ ___________ ___________ ___________
Tofu
___________ ___________ ___________ ___________ ___________ ___________
Protein Powder
___________ ___________ ___________ ___________ ___________ ___________
SERVINGS (How Much) (Indicate portion size if you dont know ounces)
Ounces
Small
Medium
Large
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FOODS
High Oxalate Foods
Spinach
Beet greens
Rhubarb
Swiss chard
SERVINGS (How Much) (Indicate portion size if you dont know ounces)
Ounces
Small
Medium
Large
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Carbohydrates
Potatoes
Bread
Rice
Pasta
Cereals
Cake, Pies
Cookies
Ice Cream
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List other simple carbohydrates that you eat and tell how often & how much:
________________________________________________________________________________________
_________________________________________________________________________________________
SERVINGS (How Much) (Indicated portion size if you dont know ounces)
Ounces
Small
Medium
Large
_________
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Butter
Yogurt Spread
Vegetable Oil
Olive Oil
Cream
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Yes No
Yes No
Yes No
Supplements/Vitamins
Yes No
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Please attach a copy of your current vitamin/supplement schedule if you desire to add additional information
LIFESTYLE
INFORMATION
Yes No
Yes No
Explain
Yes No
Do you frequently wake in the night & have trouble getting back to sleep?
_____________________
Do you breathe air that is of good quality?
Lifestyle
Yes No
Explain
Information
__________________________________________________________________________
Do you live in a healthy environment? (please check one)
Home ___ Apartment ___ Mobile Home ___ Condo/Townhome ___ Other ___
Yes No
Explain
__________________________________________________________________________
Yes No
Explain
__________________________________________________________________________
Hobbies: Please list your hobbies and indicate if you might be exposed to toxins (e.g., if you enjoy stained
glass assembly, you may be exposed to solvents, lead fumes, etc.; if you enjoy painting, you may be
exposed to solvents, petrochemicals, etc)
Hobby
Possible Exposure
___________________
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Are you now or were you ever exposed to substances that could endanger health?
(e.g., lead mercury, chemicals, dusts, fumes, gases, etc.)
Yes No
Explain
__________________________________________________________________________
What is your source of drinking water?
Filtered
Municipal
Bottled
Well
2 glasses (16oz)
4 glasses (32 oz)
Other
Day
Week
Day
Tea (regular)
Tea (herbal)
Coffee(regular)
Coffee (decaf)
Red Wine
Week
White Wine
Beer
Hard Liquor
Other
Day
Week
Explain
________________________________________________________________________
How many times do you urinate each day? ________
Does it burn when you urinate?
Do you get up at night to urinate?
Do you have a urinary tract infection?
Brown/Tan
Green or Black
Yellow or Red
1 Comments
________________________
________________________
________________________
Soft
Medium
Hard
Yes No
Yes No
Yes
Yes
yes
Yes
No
No
No
No
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____________
____________
____________
Yes No
Yes No
Yes No
Yes No
Other
____________
Have you had amalgam/silver fillings replaced with tooth colored fillings?
If yes, how many? ____________ When?__________________________
Do you have any root canal treated teeth? If yes, how many? _________
Have you had implants placed? If yes, how many? ________________
Have you had oral surgery? (Extractions, TMJ, Periodontal)
If yes, when?______________________
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Upper Denture
Splint
Yes No
Lower Denture
Night Guard
Have you ever been diagnosed with a Cavitation? (A Cavitation refers to a toxin-containing hole
so, please explain______________________________
Yes No
Did you take your saliva pH? Please indicate the average:
5.5-6.0
6.0-6.5
6.5-7.0 7.0-7.5
**The Dental Quick Report included in this packet is to be completed by your dentist or dental
hygienist.
Do you feel you have a drug habit? Yes No If yes, how many years? _______
Explain
______________________________________________________________________________________
EXERCISE INFORMATION
Do you engage in exercise or regular physical activity (totaling at least 20 minutes 5 days of the week)?
Yes No
Type
Aerobic
Duration/Workout
_______________
Times/Week
____________
Walking
________________
_____________
Running
________________
______________
Hiking
_________________
_______________
Bicycle
_________________
_______________
Eliptical Trainer
_________________
________________
Rowing
__________________
________________
Strength Training
__________________
________________
Pilates
__________________
________________
Yoga
___________________
_________________
Tai Chi
___________________
_________________
Other
__________________
_________________
Please mail the entire questionnaire along with the Dental Quick Report, pH Tracking
Chart, Informed Consent & Privacy Info. to:
Lifestyle Fitness & Nutrition
3708 Fairways Court
Fredericksburg, VA 22408
540-898-5219
Signature:
Date: