Lifestyle Assessment Form

Name:
E-mail Address:
Phone:
-
Address:
Birth date:
 /  / 
Sex:

Please answer each of the following questions.

What are your main health concerns/complaints?
Have you ever been diagnosed with an ailment related to your main health concern(s)?
Any trauma or loss in the last 5 years?
What level of stress do you feel you are experiencing at this time?
What are the major causes or factors of your stress? (check all that apply)
If other, please elaborate:
How does your stress manifest itself?
Do you use any coping mechanisms?
What do you do for exercise? (indicate type, frequency and time)
How many hours on average do you sleep daily? (include naps)
What time do you go to sleep?
Awaken?
Do you awaken feeling rested?
What is your occupation?
Do you enjoy your work?
How many hours each day do you work?
At what times do you start and end work?
Do you smoke?
If yes, how much and for how long?
If no, does anyone in your household or workplace smoke?
Do you wish to:
How much weight do you want to lose or gain?

How many hours do you spend daily, on average:

--Driving:
--Watching television:
--Reading:
--In front of computer:

What are your interests and hobbies?
Do you vacation regularly?
When was your last vacation?
Do you actively participate in any spiritual discipline (church, religious group, meditation, etc.)

MEDICAL HISTORY:
Are you currently taking any medication?
List Reason(s):
Please list any vitamins, minerals, herbal or homeopathic remedies you are currently taking and the amounts/dosages:
Do you have any allergies or sensitivities? If so, please list:
Do you have any silver-mercury fillings?
Have you ever been diagnosed with an illness?
If so, Explain:
Have you ever been hospitalized?
If so, Reason:
How often do you have a bowel movement?
Do you strain to have a bowel movement?
Do you have loose bowel movements?
Related to particular food or circumstances?
Do you use recreational drugs?
If yes, how often and what type?
Have you ever been treated for drug and/or alcohol dependency?
FAMILY HISTORY:

Hereditary Diseases: Use “F” for father, “M” for mother, “S” for sibling, “G” for grandparent, “O” for others

Heart Disease
Diabetes
Allergies
Hypertension
Arthritis
Mental Illness
Intestinal Disease
Osteoporosis
Alcoholism
Kidney Dysfunction
Ulcers
Asthma
Gall Bladder Problems
Cancer, type:
Other (please list)
FEMALES:
Are you or could you be pregnant?
Are you pre-menopausal or menopausal?
Are you experiencing any menopausal symptoms?
If yes, please specify:
Have you had a bone density test?
If yes, what was the result?

DIETARY HABITS:

How many times a day do you eat:

Main Meals
Snacks

What times of day do you eat:

Main Meals
Snacks
Do you eat meals:
Do you feel there are restrictions to your diet due to the preferences of others - Family, roommates, etc?
If yes, explain:

How many ½ cup servings of each do you typically eat in a day:

Fruit and/or vegetables:
Protein:
Whole Grains:
Dairy Products:
Other
Specify other:
What kind of fruit do you you typically eat?
What kind of vegetables you typically eat?
Type of dairy products you typically eat:
Type of protein you typically eat:

Give examples of your typical meals:

Breakfast:
Lunch:
Dinner:
Snacks:

Do you eat or use (indicate “1” for rarely, “2” for regularly, “3” for often)

aluminum pans
margarine
candy
microwave
fried foods
refined foods
luncheon meats
cigarettes
fast foods
Nutra Sweet/Aspartame

Please indicate how many cups of the following you drink per day:

bottled or spring water
tap water
milk (1% or 2%)
fresh fruit juices
beer
milk (skim)
fruit juices (prepared)
red wine
tea
fresh vegetable juices
white wine
herbal tea
soft drinks (regular)
other alcoholic
coffee
soft drinks (diet)
other (specify)
How often do you eat meat?
How often do you consume dairy products?
What are your favourite foods?
How often do you eat them?
Do you avoid certain foods? If so, why?
Do you experience any symptoms if meals are missed? Explain:
Do you experience any symptoms after meals? Explain:
Comments:
CLIENT STATEMENT:

I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being, and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily.

I agree *
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