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 Please describe the onset of current health concerns or reasons for seeking nutritional counseling. How you dealt with these issues in the past? Please indicate any recent changes you have made to help deal with these issues. What would you like to achieve, i.e. what is you goal in dealing with the above health concerns? Please list health practitioners you are currently seeing to treat your health concerns. Please indicate any medical testing you may have had regarding your current issues. Please list any vitamins, supplements, and medications which you are currently taking. Please list any diagnosed food allergies and indicate how each was diagnosed. Please list any reactions to food dyes or preservatives. Electronic Signature Your Name (required) Your Email (required) Date (required) I understand that by signing my name above and clicking "Send" below, I am electronically signing this document. Click the Send button above Wait for a "Successfully Sent" message to appear Click here to return to the Intake Forms Menu.
