Health Profile

    Health Profile

    Contact Information

    Name

    Address

    City/Town, State

    Phone

    Occupation

    How did you hear about Holistic Nutrition Services?


    Basic Health

    Age

    Gender

    FemaleMale

    Height

    Weight

    Blood Type

    Ethnicity

    Blood Pressure

    NormalHighLow

    Currently on blood pressure medication

    NoYes

    Cholesterol Range

    NormalHighLow

    Currently on cholesterol medication

    NoYes

    Diabetic

    NoType 1Type 2

    Currently on diabetes medication

    NoYes

    Thyroid Health

    NormalHypothyroidHyperthyroid

    Currently on thyroid medication

    NoYes

    Women

    MenstruatingPre-menopausalMenopausal

    Currently on birth control pills

    NoYes


    Health Issues

    Please indicate any current and past health concerns.
    Simply skip items that are not now nor have ever been a concern for you.

    Acne

    CurrentPast

    Skin hive or redness

    CurrentPast

    Runny nose

    CurrentPast

    Sinus issues

    CurrentPast

    Anxiety

    CurrentPast

    Diagnosed ADHD

    CurrentPast

    High blood sugar

    CurrentPast

    Low blood sugar

    CurrentPast

    Constipation

    CurrentPast

    Diarrhea

    CurrentPast

    Liver or gallbladder issues

    CurrentPast

    Kidney stones

    CurrentPast

    Diagnosed IBS

    CurrentPast

    Intestinal issues

    CurrentPast

    Acid stomach pain

    CurrentPast

    Loose stools

    CurrentPast

    Bloating, gas, indigestion

    CurrentPast

    Esophageal issues

    CurrentPast

    Ulcer

    CurrentPast

    Parasites

    CurrentPast

    Difficulty losing weight

    CurrentPast

    Difficulty gaining weight

    CurrentPast

    High blood pressure

    CurrentPast

    High cholesterol

    CurrentPast

    Hypoglycemia

    CurrentPast

    Thyroid conditions

    CurrentPast

    Stroke

    CurrentPast

    Depression

    CurrentPast

    Memory loss or confusion

    CurrentPast

    Heart disease or problems

    CurrentPast

    Osteoporosis

    CurrentPast

    Arthritis (Osteo or Rheumatoid)

    CurrentPast

    Anemia

    CurrentPast

    Pregnant or nursing

    CurrentPast

    Cancer

    CurrentPast

    Colds or flu (frequent)

    CurrentPast

    Chronic fatigue

    CurrentPast

    Yeast or fungal infections

    CurrentPast

    Nails (poor growth)

    CurrentPast

    Hair loss or poor growth

    CurrentPast

    Diabetes I (insulin dependent)

    CurrentPast

    Diabetes II (adult onset)

    CurrentPast

    Diagnosed Anorexia

    CurrentPast

    Diagnosed Bulimia

    CurrentPast

    Asthma

    CurrentPast

    Hay fever

    CurrentPast

    Animal allergies

    CurrentPast

    Reactions to chemical inhalants

    CurrentPast

    Diverticulitis

    CurrentPast

    Pre-diabetic/High A1C

    CurrentPast


    Symptoms

    Please check any of the following symptoms which you experience regularly.

    Indigestion

    Bloating

    Flatulence (gas)

    Diarrhea

    Craving salt

    Craving sweets

    Craving bread

    Hunger within 2 hours after a meal

    Loss of appetite

    Nausea

    Acid reflux

    Constipation

    Forgetfulness

    Poor memory

    Poor focus

    Headaches or migraines

    Fatigue

    Depression

    Stress

    Tiredness or Weakness upon missing a meal

    Impatience

    Irritability

    Insomnia

    Trouble losing weight

    Joint pain

    Abdominal pain

    High blood pressure

    Dizziness upon standing

    Sneezing

    Runny nose

    Thirsty

    Dry skin or hair


    Digestion

    Do you have bowel movements
    at least once per day?

    AlwaysOccasionalNever

    Do you experience constipation?

    AlwaysOccasionalNever

    Do you experience diarrhea?

    AlwaysOccasionalNever

    Do you experience alternating
    diarrhea and constipation?

    AlwaysOccasionalNever

    Do you experience abdominal pain?

    AlwaysOccasionalNever

    Have you been diagnosed with IBS?

    YesNo



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