Eat Heal Love™ — Nutrition and Life Style Assessment Form
Please allow yourself at least 45 minutes to fill out the following questionnaire.
The more information you can provide, the more thorough your assessment will be.
Email address *
First name *
Your answer
Last name *
Your answer
Email address *
Your answer
Today's Date *
Your answer
Age *
Your answer
Biological Sex *
What is your main purpose for booking this consultation? *
Your answer
What are your main health concerns/complaints? *
Your answer
Have you ever been diagnosed with an illness?
If yes, please explain.
Your answer
Have you ever been hospitalized for any reason?
If yes, please explain
Your answer
Are you currently taking any medications?
If yes, please list
Your answer
Please list any vitamins, minerals, herbal or homeopathic supplements you are currently taking
Include amounts/dosages
Your answer
Do you wish to lose or gain weight? *
Please indicate how much weight you want to gain or lose.
Your answer
Females, could you be pregnant?
Females: Are you currently taking birth control pills?
Have you ever had a bone density test and if so, what were the results?
Your answer
Have you experienced any trauma or stressful event in the past 5 years?
What level of stress you are experiencing at this time? *
What are the major causes of your stress?
If no, do you suspect you have any food intolerances or sensitivities?
If yes, please explain.
Your answer
If yes, please feel free to explain
Your answer
How does stress manifest itself?
i.e. headaches, moodiness, stiff neck, lack of appetite
Your answer
Do you use any coping mechanisms?
Feel free to explain
Your answer
How often to you exercise?
What do you do for exercise?
Your answer
Do you smoke?
If yes, how long?
Your answer
Do you use recreational drugs?
If yes, what type and how often?
Your answer
Have you ever been treated for drug and/or alcohol dependancy?
What is your occupation?
Your answer
On average, how many hours do you sleep? (including naps) *
Your answer
What time do you go to sleep? *
Your answer
What time do you wake up? *
Your answer
Do you wake feeling rested? *
Have you been diagnosed with any allergies or food sensitivities?
Your answer
How would you describe your current diet? *
Required
Meals are usually eaten:
Check all that apply
Are there any restrictions to your diet due to the preferences of others? (family, roomates etc.)
If yes, please explain
How often do you consume meat? *
Includes all cuts of meat(chicken, steak, turkey, bacon, ham, lunch meat)
Required
How often do you consume dairy? *
Includes milk, cheese, butter, yogurt, ice cream, sour cream, cream cheese etc.
Required
How many servings of grains to do you consume daily? *
ex: rice, bread, pasta
How many meals do you eat a day?
Your answer
Do you eat breakfast? *
If yes, what time and what would it typically consist of? *
Please give as many examples of your typical breakfast as you can.
Your answer
What time do you have lunch and what does it normally consist of? *
Your answer
What time and type of meals do you normally have for dinner? *
Your answer
What do you usually eat for snacks? *
Please list the times
Your answer
Please list everything you ate and drank yesterday *
Your answer
Do you drink water with your meals *
Do you have a bowel movement every day?
Do you ever see undigested food in the stool?
Do you ever strain to have a bowel movement?
Do you ever have loose bowel movements?
Do you notice if loose or strained bowel movements are related to any particular food?
Please explain
Your answer
Do any foods cause gas and bloating?
Please explain
Your answer
How many cups of tap water do you drink per day? *
or more
How many cups of filtered water do you drink per day? *
or more
How many cups of store bought fruit juice do you drink per day?
How many cups of fresh fruit juice do you drink per day?
How many cups of fresh vegetable juice do you drink per day?
How many soft drinks do you drink per day?
How many diet soft drinks do you drink per day?
How many beers do you drink per day?
How many glasses of wine do you drink per day?
How many cups of other alcoholic drinks do you drink per day?
How many cups of milk (1% or 2%) do you drink per day? *
How many cups of skim milk do you drink per day? *
How many cups of soy milk do you drink per day? *
How many cups of milk alternative (rice, almond, hemp, etc) do you drink per day?
How many cups of black tea do you drink per day?
How many cups of herbal tea do you drink per day?
How many cups of coffee do you drink per day? *
Do you have any mercury fillings?
How often you use a microwave?
How often you use consume lunch meat? *
How often you use artificial sweeteners like Splenda, Nutra Sweet or Aspartame? *
How many teaspoons of added sugar do you consume a day? *
This includes white sugar, brown sugar, palm sugar, cane sugar, raw sugar
Your answer
How often do you eat fried foods?
How often do you use margarine?
How often do you consume candy and sweets?
How often do you eat fast food?
What are your favourite foods and how often do you eat them? *
Your answer
Do you avoid certain foods? *
If so, why?
Your answer
Do you experience any symptoms if meals are missed? *
Explain
Your answer
Do you experience any symptoms after meals? *
Explain
Your answer
Do you ever have heart burn or indigestion? *
How would you rate your energy levels? *
Metabolic Rate
Frequent illness or infections *
Do you have bad breath or body odor?
Do you have bags or dark circles under your eyes? *
Do you crave sugar, bread or alcohol? *
Do you give in to your cravings? *
Do you have difficulty digesting certain food? *
Your answer
Have you used antibiotics in the past 10 years? *
When was the last time you were on antibiotics?
Your answer
Do you suffer from acne, psoriasis, dermatitis or eczema? *
Do you suffer from bronchitis, asthma, pneumonia or emphysema? *
Do you suffer from a chronic cough? *
Do you suffer from headaches? *
Do you ever have dizzy spells? *
Do you have periods of confusion? *
Do you have poor concentration? *
Do you suffer from muscle cramps or spasms? *
Do you experience excessive sweating or night sweats? *
Do you have joint pain or stiffness?
Do you experience wheezing or difficulty breathing? *
Do you experience stuffy or runny nose? *
Do you notice changes in your writing throughout the day? *
Do you suffer from canker sores? *
How would you rate your exposure to toxins and chemicals? *
Do you experience frequent mood swings? *
Do you get depressed or irritable? *
Do you have dry, brittle hair or split ends? *
Do you have a high cholesterol, high fat diet? *
Do you suffer from insomnia or restless sleep? *
Do you have a low fiber diet? *
Females: Do you suffer from menstrual cramps or PMS?
Do you have cellulite?
Do you have cold hands and feet? *
Do you have varicose veins?
Do you suffer yeast of fungal infections? *
Do your bones break easily or do you have osteporosis? *
Do you have food or chemical sensitivities? *
Do you ever have racing thoughts or feel out of control?
Do you have exsessive mucous? *
Do you have shortness of breath climbing stairs? *
Do you get tingling in your lips, fingers, arms or legs? *
Do you experience chest pains?
Do you have either a very rapid or slow heart rate?
Do you have painful, hard or thin bowel movements? *
Do you ever suffer from constipation? *
Do you ever have blood in the stool? *
Do you have recurrent bladder infections? *
Do you have painful or difficulty urinating?
Do you experience frequent urination? *
Do you experience swollen glands or puffy throat?
Do you experience lower abdominal pain?
Do you have sinus inflammation or discharge? *
Do you experience lower back pain?
Do you experience water retention?
Do you have a low sex drive?
Do you feel heavy or bloated after meals? *
Do you experience gas, belching or burping after meals?
Do you ever feel tired after meals? *
Do you eat when rushed or in a hurry? *
Do you experience nausea after taking supplements?
Do you have undigested food in the stool?
Do you have longitudinal striations on the fingernails?
Do you experience pain in the stomach 1 hour after eating?
Do you experience a burning sensation in the stomach?
Do you experience pain in the stomach that is aggravated by worry or tension? *
Do you have been dignosed with hiatal hernia