Health Profile

    Health Profile

    Contact Information
    City/Town, State
    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

    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

    Do you have bowel movements
    at least once per day?
    Do you experience constipation? AlwaysOccasionalNever
    Do you experience diarrhea? AlwaysOccasionalNever
    Do you experience alternating
    diarrhea and constipation?
    Do you experience abdominal pain? AlwaysOccasionalNever
    Have you been diagnosed with IBS? YesNo

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