Health Profile

Health Profile

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    Contact Information
    How did you hear about Holistic Nutrition Services?

    Basic Health
    GenderFemaleMale
    Blood PressureNormalHighLow
    Currently on blood pressure medicationNoYes
    Cholesterol RangeNormalHighLow
    Currently on cholesterol medicationNoYes
    DiabeticNoType 1Type 2
    Currently on diabetes medicationNoYes
    Thyroid HealthNormalHypothyroidHyperthyroid
    Currently on thyroid medicationNoYes
    WomenMenstruatingPre-menopausalMenopausal
    Currently on birth control pillsNoYes

    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.
    AcneCurrentPast
    Skin hive or rednessCurrentPast
    Runny noseCurrentPast
    Sinus issuesCurrentPast
    AnxietyCurrentPast
    Diagnosed ADHDCurrentPast
    High blood sugarCurrentPast
    Low blood sugarCurrentPast
    ConstipationCurrentPast
    DiarrheaCurrentPast
    Liver or gallbladder issuesCurrentPast
    Kidney stonesCurrentPast
    Diagnosed IBSCurrentPast
    Intestinal issuesCurrentPast
    Acid stomach painCurrentPast
    Loose stoolsCurrentPast
    Bloating, gas, indigestionCurrentPast
    Esophageal issuesCurrentPast
    UlcerCurrentPast
    ParasitesCurrentPast
    Difficulty losing weightCurrentPast
    Difficulty gaining weightCurrentPast
    High blood pressureCurrentPast
    High cholesterolCurrentPast
    HypoglycemiaCurrentPast
    Thyroid conditionsCurrentPast
    StrokeCurrentPast
    DepressionCurrentPast
    Memory loss or confusionCurrentPast
    Heart disease or problemsCurrentPast
    OsteoporosisCurrentPast
    Arthritis (Osteo or Rheumatoid)CurrentPast
    AnemiaCurrentPast
    Pregnant or nursingCurrentPast
    CancerCurrentPast
    Colds or flu (frequent)CurrentPast
    Chronic fatigueCurrentPast
    Yeast or fungal infectionsCurrentPast
    Nails (poor growth)CurrentPast
    Hair loss or poor growthCurrentPast
    Diabetes I (insulin dependent)CurrentPast
    Diabetes II (adult onset)CurrentPast
    Diagnosed AnorexiaCurrentPast
    Diagnosed BulimiaCurrentPast
    AsthmaCurrentPast
    Hay feverCurrentPast
    Animal allergiesCurrentPast
    Reactions to chemical inhalantsCurrentPast
    DiverticulitisCurrentPast
    Pre-diabetic/High A1CCurrentPast

    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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