First
Name: |
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Last Name: |
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Address: |
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City: |
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State: |
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Zip Code:
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Home Phone: |
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Business Phone: |
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Fax: |
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E-mail Address: |
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Have
you had any illnesses in the past 10 years? |
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Please List |
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Are
you currently taking any medications? |
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If
Yes Please List |
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What
was your blood pressure at your assessment? (or if you know
your last reading) |
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Do
you know your cholesterol? |
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If YES, please enter: |
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Please List
Your Family's Health History |
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LIFESTYLE |
How many times a week do you exercise? |
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Please explain your current exercise regimen: |
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Do you smoke? |
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If Yes how much? |
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Do You Drink
Alcohol? |
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If YES how much? |
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Is your energy
lower now than it used to be? |
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How many
times a week do you eat out in restaurants and what type of
food? |
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Do you eat fast
food? |
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How Often? |
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Where do you eat
fast food? |
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If OTHER please
specify |
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Do you have
difficulty sleeping? |
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How many hours a
night do you sleep? |
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DIET ANALYSIS |
How many meals do you eat per day? |
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How often do you eat products made with white flour?
(breads, cereal, etc)
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How many teaspoons of sugar do you add to food or drink
per day?
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Do you use sugar substitutes? |
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If YES, which sugar substitutes? |
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Do you add salt to foods? |
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How many cups
of coffee do you drink per day? |
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How many cups
of tea? |
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How often
do you drink soda, iced tea, juices etc?
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How many
glasses or how many ounces of water per day ?(please
specify) |
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How often do
you eat red meat? |
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How often do
you eat fruit & vegetables? |
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How often do you eat dairy products & is it low fat? (milk, cheese, yogurt) |
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How many times a week do you eat eggs? |
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How often do you eat cake & cookies? |
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Candy? |
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Ice Cream? |
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Do you frequently eat under stressed or emotional conditions? |
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Do you skip meals frequently? |
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Is there a time during the day when you crave a specific type of food? |
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If YES, please enter time and which food: |
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How would you describe your appetite? (e.g.; good, fair, poor) |
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Have you tried fad diets in the past? Which ones? |
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Do you take nutritional supplements or vitamins? Please indicate: Yes or No and specifics including product manufacturer. |
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What are your food preferences/likes? |
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What are the foods you dislike? |
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Please write the food and drink you might consume in a
“typical” day and the time of the meal.
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Breakfast
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Time
Food
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Snack
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Time
Food
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Lunch |
Time
Food
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Snack |
Time
Food
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Dinner |
Time
Food
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Snack |
Time
Food
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