Female Intake Questionnaire Name * First Name Last Name Date of Birth MM DD YYYY Email * Phone (###) ### #### Genetic Background: ... African American Hispanic Mediterranean Asian Native American Caucasian Northern European Other Other: What, where, and from whom did you last receive medical or health care? Emergency Contact: First Name Last Name Relationship: Phone (###) ### #### Current Health Concerns Please rank current and ongoing health concerns in order of priority Describe Problem Example: Post Nasal Drip Severity Mild Moderate Severe Prior Treatment/Approach Example: Elimination Diet Success Excellent Good Fair 2. Severity Mild Moderate Severe Prior Treatment/Approach Success Excellent Good Fair Allergies Name of Medication/Supplement/Food: 1. Reaction: 2. Reaction: 3. Reaction: 4. Reaction: 5. Reaction: Lifestyle Review Sleep How many hours of sleep do you get each night on average? Do you have problems falling asleep? Yes No Staying asleep? Yes No Do you have problems with insomnia? Yes No Do you snore? Yes No Do you feel rested upon awakening? Yes No Do you use sleeping aids? Yes No If yes, explain: Exercise Cardio/Aerobic Strength/Resistance Flexibility/Stretching Balance Sports/Leisure (e.g., golf) Other: Do you feel motivated to exercise? Yes A little No Are there any problems that limit exercise? Yes No If yes, explain: Do you feel unusually fatigued or sore after exercise? Yes No If yes, explain: Nutrition Do you currently follow any of the following social diets or nutritional programs? (Check all that apply) Vegetarian Vegan Allergy Elimination Low Fat Low Carb High Protein Blood Type Low Sodium No Dairy No Wheat Gluten Free Other: Do you have sensitivities to certain foods? Yes No If yes, list food and symptoms Do you have an aversion to certain foods? Yes No If yes, explain: Do you adversely react to: (Check all that apply) Monosodium glutamate (MSG) Artificial sweeteners Garlic/onion Cheese Citrus foods Chocolate Alcohol Red wine Sulfite-containing foods (wine, dried fruit, salad bars) Preservatives Food coloring Other food substances: Are there any foods that you crave or binge on? Yes No If yes, what foods? Do you eat 3 meals a day? Yes No If no, how many Does skipping a meal greatly affect you? Yes No How many meals do you eat out per week? 0-1 1-3 3-5 >5 meals per week Check the factors that apply to your current lifestyle and eating habits: Fast eater Eat too much Late-night eating Dislike healthy foods Time constraints Travel frequently Eat more than 50% of meals away from home Healthy foods not readily available Poor snack choices Significant other or family members don't like healthy foods Significant other or family members have special dietary needs Love to eat Eat because I have to Have negative relationship to food Struggle with eating issues Emotional eater (eat when sad, lonely, board, etc.) Eat too much under stress Don't care to cook Confused about nutrition advice Diet Please record what you eat in a typical day: How many servings do you eat in a typical week of these foods: Radio Option 1 Option 2 Line Thank you!
