Step 1 of 5 20% BACKGROUND DATAFirst Name*Last Name*Phone Number*Date of Birth*Height*Weight*Usual Weight*Waist Size* HEALTH HISTORY1. Known health disorder (check any that apply and record type) Hypertension Cancer Diabetes GI Disorders Heart Disease HIV infection Recent major illness Trauma or Surgery Kidney disease Liver disease Lung disease Pancreatic disease Physical disability Alcoholism High Cholesterol Overweight Physical Disability Ulcers Obesity Celiac disease Mental health disorder Depression Dis. of Nervous System Gall Stones Other If answered "Other"2. Symptoms (check any that apply and record reason if known): Chronic fatigue Constipation Depression Indigestion Fever Nausea Difficulty chewing Lack of appetite Vomiting Difficulty swallowing Other If answered "Other"3. Tobacco use:*YesNoType of Tobacco and Amount4. List average number of hours sleep per night:*5. How would you describe your excerise history? (select one only) I am not currently active I am currently active but have begun doing so in the last 6 months I participate in regular activity and have done so for more than 6 months 6. How would you rate your overall stress level? Low Medium High SUPPLEMENT HISTORY1. Do you currently take any vitamins or mineral supplements?*YesNo1a. If answered yes, please list (Type e.g. name, Dose and Frquency):2. Do you currently take or have taken any herbal supplements in the last 3 months?*YesNo2a. If answered yes, please list (Type e.g. name, Dose and Frquency):3. Do you currently take Prescription or over-the-counter Medications ?*YesNo3b. If answered yes, please list (Type e.g. Name, Dose, Frquency and Reason): DIET HISTORY1. Do you have ready access to fresh fruits and vegetables?*YesNo2. Do you have access to a juicer?*YesNo3. Do you have access to a blender?*YesNo4a. Do you have any food allergies or sensitivities?*YesNo4b. If yes, check any of the common foods or triggers that render an allergic response: i. Peanuts ii. Tree Nuts (walnuts, pecans, almonds) iii. Gluten iv. Milk v. Shellfish vi. Soy vii. Wheat viii. Eggs ix. Fish x. Other(s) If answered "Other"5a. Do you have a special diet?*YesNoIf so, What Type and How Long?*5b. Do you have a restrictive diet?*YesNoIf so, What Type and How Long?*6. Do you frequently eat out?*YesNo7. Do you omit food groups (if so, describe)?8. Alcohol Use:*DailyA few times a weekA few times a monthRarelyNever9. Do you drink the following beverages often? (Check any that apply)* i. Diet Coke ii. Coffee iii. Soda iv. Fruit Juice v. Smoothies vi. Energy Drink vii. Water viii. Milk ix. Raw Fresh Juices DIET HISTORY (CONTINUED...)10. How many cups (8 oz) of water do you drink daily?*11. Do you incorporate green vegetables into my diet on a daily basis? (Green vegetables include: Kale, Spinach, Bok Choy, Broccoli, Collards, Sea Weed, Asparagus, Dark colored lettuce, Swiss Chard, etc.)*YesNo12. How often do you eat vegetables or fruits?*Every DayNot Every Day13. On an average day, how many 1/2 cup servings of fresh, canned, frozen or dried vegetables do you eat?*12-34-56 or moreNone14. On an average day, how many sugar-sweetened beverages (soda, sweet tea, juice, energy/sports drinks, coffee) do you drink?*12-34-56 or moreNone15. On an average day, how many times do you eat meat/fish?*12-34-56 or moreNone16. On an average day, how many times do you eat beans?*12-34-56 or moreNone17. Do you eat breakfast on a daily basis? (if so, please list typical breakfast)*18. How do you rate your healthy eating habits overall?*PoorFairGoodVery GoodExcellent
