Lifestyle Assessment Form

Client Alias: *

Date *

MM

/

DD

/

YYYY

Age *

Sex *

Male

Female

Other:

What is your purpose in coming here today? *

What are your main health concerns/complaints? Please list in priority: *

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? Please quantify on a scale of 1 to 10: *

No Stress

1

2

3

4

5

6

7

8

9

10

Overwhelming Stress

What are the major causes or factors of your stress? (Check all that apply) *

Financial

Family

Career

Spiritual

Personal

Marriage

Health

Unfulfilled Expectations

Other:

Required

How does your stress manifest itself? *

What coping mechanisms do you use? *

What do you do for exercise? *

(Indicate type, frequency, time of day and duration)

For how long have you been with this exercise program? *

On a scale of 1-10, how would you describe your energy levels? *

Very low energy

1

2

3

4

5

6

7

8

9

10

Very high energy

Do you experience any lulls or highs in your energy levels throughout the day? Is so, at what time of day? *

How many hours on average do you sleep daily? *

(Include naps)

What time do you go to sleep? Awaken? *

Do you have trouble: *

(click all that apply)

Falling asleep?

Staying asleep?

N/A

Required

Do you wake up feeling rested? *

(click all that apply)

Yes

No

What is your occupation? *

Do you enjoy your work? *

Yes

No

Sometimes

How long have you been at your current job? *

How many hours each day do you work? *

At what times do you start and end work? *

Do you do work shifts or are you on a regular schedule? *

Do you or have you ever smoked? If so, how much and for how long? *

If no, does anyone in your household or workplace smoke? *

Do you wish to gain weight? Lose weight? If so, How much? *

What is your main motivation to change your weight? *

When, if ever, were you at your ideal weight? *

Have you tried weight loss programs in the past (if so, please describe)? *

What were the results? *

What did you like/dislike about the program(s)? *

Below, please write in the number of hours spent doing the following, each day: *

0

1

2

3

4

5

6

7

8 or more

Driving

Watching TV

Reading

In Front of the Computer

What are your interests and hobbies? *

Do you vacation regularly? *

Yes

No

When was your last vacation? *

Do you actively participate in any spiritual discipline (church, religious group, meditation, etc)? *

Yes

No

MEDICAL HISTORY

Are you currently taking any medication(s)? *

Yes

No

If so, what are you taking, and for which condition?

Do you take birth control? *

Yes

No

Have you ever taken birth control? If so, for how long? What type? When did you stop? *

Are you on anti-depressants? *

Yes

No

Have you taken antibiotics over the past 5 years? *

Yes

No

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? *

These appear as black or silver fillings in your mouth.

Yes

No

I had them, but they were removed and replaced

Have you ever been diagnosed with an illness? *

If yes, please explain.

Have you ever been hospitalized? *

If so, for what reason?

Have you had surgery to remove your gall bladder? Tonsils? Appendix? *

Please specify which one below.

How often do you have a bowel movement? *

Do you strain to have a bowel movement? *

Yes

No

Occasionally

If you answered yes above, is it related to a particular food or circumstance that you are aware of?

Do you ever experience loose bowel movements? *

Yes

No

Occasionally

If you answered yes above, is it related to a particular food or circumstance that you are aware of?

Do you use recreational drugs? *

Yes

No

If yes, how often and what type?

Have you ever been treated for drug and/or alcohol dependency? *

Yes

No

FAMILY HISTORY

Please indicate which diseases typically "run" in your family. *

Mother

Father

Both Mother and Father

Sibling

Grandparents

Multiple Family Members

Other Family Member

Condition Does NOT exist in my family

Allergies

Alcoholism

Arthritis

Asthma

Autoimmune Disease

Cancer

Diabetes

Drug Abuse

Gall Bladder Problems

Heart Disease

Hypertension

Intestinal Disease

Kidney Dysfunction

Mental Illness

Osteoporosis

Skin Conditions

Ulcers

FEMALES

Are you or could you be pregnant?

Yes

No

Clear selection

Have you noticed any changes in your menses, for example, in the frequency, duration, flow, clotting, etc?

Please specify.

Do you suffer from PMS symptoms?

Please specify.

Have you ever been pregnant?

Please specify.

Yes

No

Clear selection

Are you currently Breastfeeding?

Please specify.

Yes

No

Clear selection

Are you pre-menopausal? Are you post-menopausal?

Are you experiencing any menopausal symptoms?

If yes, please specify.

Have you had a bone density test? What was the result?

DIETARY HABITS

How many times a day do you eat? *

How many main meals do you eat per day? What times of the day do you eat them? *

How many snacks do you eat per day? What times of the day do you eat them? *

How do you eat your meals? *

With family

Home alone

At a restaurant

Fast food

On the run

While working

Other

Required

Do you feel there are restrictions to your diet due to preferences of other such as family, roommates, etc? *

If yes, please explain.

How may 1/2 cup servings of fruit do you typically eat in a day? *

Fresh, dried, canned, frozen

How may 1/2 cup servings of vegetables do you typically eat in a day? *

Cooked, raw, canned, frozen

How may 1/2 cup servings of whole grains do you typically eat in a day? *

How may 1/2 cup servings of protein do you typically eat in a day? *

Please include protein type as well (beans, tofu, chicken, beef, etc)

How may 1/2 cup servings of dairy do you typically eat in a day? *

Please include the type of dairy you consume (milk, cheese, ice cream, yogurt, cottage cheese, etc)

Please specify any other category of food that you typically consume that is not listed on here:

Give examples of your typical breakfast meals: *

Give examples of your typical lunch meals: *

Give examples of your typical dinner meals: *

Give examples of your typical snacks: *

Please Indicate to what extent you eat or use the following: *

Rarely

Regularly

Often

Aluminum Pans

Microwave

Lunch Meats

Nutra Sweet/ Aspartame

Margarine

Fried Foods

Cigarettes

Candy

Refined Foods

Fast Foods

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

0 cups

1-3 cups

4-7 cups

8 cups or more

Beer

Coffee

Tap Water

Soft Drinks (diet)

Soft Drinks (regular)

Fruit juices (store bought)

Milk (1% or 2%)

Milk (Vitamin D)

Freshly squeezed vegetable juices

Red Wine

White Wine

Other alcoholic beverages

Tea

Freshly squeezed fruit juices

Bottled or Spring Water

Herbal Tea

Junk Food

Other

Are you a: *

Meat eater?

Vegetarian?

Vegan?

Fruitarian?

Raw foodist?

How often do you eat meat? *

Daily

3-5 times per week

Once a week or less

Never

How often do you consume dairy products? *

Daily

3-5 times per week

Once a week or less

Never

What are your favorite 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: *

Any other general comments at this time? *