health history forms - nutritional weight & wellness · personal information, save often while...

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Submit your completed Health History Forms to Nutritional Weight & Wellness:• E-mail your forms to [email protected], • Fax them to 651-695-0191, or• Mail* them to our Wayzata office: 18480 Kenyon Ave, Lakeville, MN 55044 *This must be done 5-7 days prior to your appointment so we receive your forms in time.

Health History Forms

Thank you for choosing Nutritional Weight & Wellness for your nutrition consultation!

Every day we see nutrition improve the lives of our clients, and we look forward to seeing what nutrition can do for you.

Your initial nutrition consultation will last approximately two hours.

Prior to your appointment — Complete the enclosed Health History Forms

On the day of your appointment

1. Please arrive at least five minutes prior to the scheduled time of your appointment.2. Bring any prescription medications or supplements you are currently taking, as well as any lab results you

would like to discuss.3. Please refrain from wearing perfume or cologne as many of our clients are sensitive to scents.4. Please note that payment is due in full at the time of your appointment.Some insurance companies will reimburse you for nutrition counseling If you would like to submit a claim to your insurance company, contact the member services department of your insurance provider to check cover-age. Nutritional Weight & Wellness is considered an out-of-network provider. If you choose to submit a claim, we will provide the necessary information at the time of your visit.

If you have any questions, please call 651-699-3438 or toll free (800) 805-8954

Offices in St. Paul, Wayzata, North Oaks, Lakeville and Maple Grove | 651-699-3438 | weightandwellness.com© 2012 Nutritional Weight & Wellness, Inc.

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If for any reason you must call and cancel this appointment or future appointments, please give 24-hour advanced notice.

w e i g h t a n d w e l l n e s s . c o m©2011 Nutritional Weight & Wellness, Inc. 1

Women: please check any that pertain

PMS birth control pills irregular periods loss of libido painful periods menopause loss of periods painful intercourse children # _____ hysterectomy

Men: please check any that pertain

frequent urination difficulty with urination difficulty with erection loss of libido prostate enlargement

Past PresentAcne Addiction (alcohol, drugs) Anemia Anorexia/Bulimia Anxiety or nervousness Arthritis (Rheumatoid/Osteo) Bladder infections (Cystitis) Bloating, gas Blood sugar problems Bronchitis Cancer Celiac disease Colds or flu (frequent) Cold sores Chronic fatigue Constipation Dandruff Depression Diabetes I (insulin dependant) Diabetes II (adult onset) Diarrhea

Past PresentDifficulty losing weight Difficulty gaining weight Eczema Emotional problems (instability or sensitivity)Emphysema Fainting Gall bladder problems Gout Hair loss or poor hair growth Headaches Heart disease or problems Heartburn, indigestion Hemorrhoids Herpes simplex, type II High blood pressure High cholesterol HIV Hot flashes Hypoglycemia Insomnia Intestinal problems

Past PresentKidney stones Liver problems Loose stools Memory loss or confusion Nails, poor growth Nails, white spots Osteopenia/Osteoporosis Panic attacks Parasites Pregnant/nursing mother Psoriasis Respiratory problems Ringing in ears Seizures Severe mood swings Skin conditions Stroke Suicidal tendencies Thyroid condition Ulcer Yeast infections

Health History Please check any that apply to you (past or present)

Name ___________________________________Date: ___________________DOB: _________________________Address __________________________________ City _______________ State/Zip _________________________Phone: (H) ______________ (C) _______________ Email: ______________________________________________Age: _______ Height: ______ Weight: _______ Cholesterol: _____________Blood Pressure: ________________Occupation: ______________________________________ Work Hours: ___________________________________Reason and goals for consultation: ________________________________________________________________________________________________________________________________________________________________For follow-up, which is the best way to reach you? Phone Email

Nutrition Questionnaire

Appointment Date: ___________________ Nutritionist: _______________________

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Diet ReviewDescribe a typical day’s meals (including snacks, drinks, time of each). Be as specific as you can.

Breakfast: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Usual time: __________Lunch: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Usual time: __________Dinner: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Usual time: __________Snacks: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Usual time(s): ________ How many times do you usually eat per day? _________________________________________________________How many 8 oz. glasses of water do you drink per day? ________________________________________________

Do you drink: coffee How many 8 oz. per day? _______________________________________________ soda How many 8 oz. per day? _______________________________________________ tea How many 8 oz. per day? What type? _____________________________________ fruit juice How many 8 oz. per day? _______________________________________________ alcohol How many drinks per day/week/month? ____________________________________

Do you get noticeably irritable, light-headed, or weak if you haven’t eaten in a while? ________________________Do you often skip meals? ________________ If yes, which do you most commonly skip? ______________________What times(s) of the day are you most hungry? _______________________________________________________

Do you crave: sugar meat fat chocolate fish alcohol desserts milk bread fried foods other _____________________________________

Do you consume: butter peanut oil canola oil margarine corn oil sunflower/safflower oil olive oil Crisco mayonnaise coconut oil vegetable oil flaxseed oil soybean oil other _____________________________________

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What are your favorite foods? ___________________________________________________________________________________________________________________________________________________________________What foods do you strongly dislike? ______________________________________________________________________________________________________________________________________________________________Are you currently under a physician’s care for a chronic health problem that requires continuous monitoring?If yes, please explain. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please list any medications you are currently taking: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you take any nutritional supplements or vitamins? Please list if yes (attach list if necessary). ____________________________________________________________________________________________________________________________________________________________________________________________Please list any disease, illness, or ailments in your immediate family (i.e. mother, father, grandparents).____________________________________________________________________________________________________________________________________________________________________________________________Please feel free to expand on any concerns you feel are relevant to your health.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you have any food allergies, restrictions or sensitivities? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Lifestyle FactorsDo you exercise? ____________ If so, what kind? ______________________________________________________Frequency? ____________________________________________________________________________________

Please rate the following:

Daily energy level: Daily stress level: Energy after exercise: General enjoyment of life:

Excellent Very high Excellent Excellent Good High Good Good Fair Moderate Fair Fair Poor Low Poor Poor

None• • • • •

Do you consider yourself: relaxed stressed highly stressedDo others consider you: inactive active very activeAre you: often tired occasionally tired rarely tired

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Check all that apply: I like to interact with others I concentrate and complete tasks People generally enjoy my company I am distracted easily I have many friends I can only focus on specific tasks I prefer to spend time alone

How much sleep do you get on average each night? ____________________________________________________Any problems sleeping? ___________________________________________________________________________Do you smoke? ___________ Have you recently quit smoking? ____________________________________________How is your dental health? _________________________________________________________________________How often do you have bowel movements? ____________________________________________________________How often do you urinate? _________________________________________________________________________

Do you consider yourself a: light eater moderate eater heavy eaterAre you often hungry? ________ if yes: when you wake up late morning mid afternoon all day long end of the day before going to bed all night

How often do you eat out? ________________________________________________________________________What restaurants? ________________________________________________________________________________

Do you eat: alone with friends with spouse/significant otherDo you often skip meals? ______ if yes: breakfast lunch dinnerDo you have children? ________ if yes, how many? __________________Ages: ____________________________

I think my goals are: easy to achieve very difficult to achieve difficult to achieve impossible to achieve

If weight loss is one of your stated goals, please complete the following questions

Do you feel you’ve always had a weight problem? _____________________________________________________If not, around what age did you first notice that you had gained weight? _____________________________________What do you feel your weight gain was caused by? ____________________________________________________________________________________________________________________________________________________

At my ideal weight, I should: be in my best state of health be more active and full of energy be more comfortable around others be wearing clothes I’ve outgrown

What diets have you tried in the past? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you ever had any health problems as a result of dieting? ____________________________________________If yes, what problems? ____________________________________________________________________________________________________________________________________________________________________________Please list any surgeries you’ve had: ________________________________________________________________________________________________________________________________________________________________

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Health SurveyRate each of the following symptoms based upon your health profile for the past 6 months:

POINT SCALE: 0 = Never or Almost Never have the symptoms 1 = Occasionally have it, effect is Not Severe 2 = Occasionally have it, effect is Severe 3 = Frequently have it, effect is Not Severe 4 = Frequently have it, effect is Severe

Digestive_______ Nausea or vomiting_______ Diarrhea_______ Constipation_______ Bloated feeling_______ Belching, passing gas_______ Heartburn_______ TOTAL

Ears_______ Itchy ears_______ Earaches, ear infections_______ Drainage from ear_______ Ringing in ears_______ Hearing loss_______ TOTAL

Emotions_______ Mood swings_______ Anxiety, fear, nervousness_______ Anger, irritability_______ Depression_______ TOTAL

Energy/Activity_______ Fatigue, sluggishness_______ Apathy, lethargy_______ Hyperactivity_______ Restlessness_______ TOTAL

Eyes_______ Watery, itchy eyes_______ Swollen, red, or sticky eyelids_______ Dark circles under eyes_______ Blurred or tunnel vision_______ TOTAL

Heart_______ Skipped heartbeats_______ Rapid heartbeats_______ Chest pain_______ TOTAL

Lungs_______ Chest congestion_______ Asthma, bronchitis_______ Shortness of breath_______ Difficulty breathing_______ TOTAL

Mind_______ Poor Memory_______ Confusion_______ Poor concentration_______ Poor coordination_______ Difficulty making decisions_______ Stuttering, stammering_______ Slurred speech_______ Learning disabilities_______ TOTAL

Mouth/Throat_______ Chronic coughing_______ Gagging, clears throat frequently_______ Sore throat, hoarse_______ Swollen, discolored tongue, gums, or lips_______ Canker sores_______ TOTAL

Nose_______ Stuffy nose_______ Sinus problems_______ Sinus Drainage_______ Hay fever_______ Sneezing attacks_______ Excessive mucus_______ TOTAL

Skin_______ Acne_______ Hives, rashes, dry skin_______ Hair loss_______ Flushing or hot flashes_______ Excessive sweating_______ TOTAL

Head_______ Headaches_______ Faintness_______ Dizziness_______ Insomnia_______ TOTAL

Joints/Muscles_______ Pain or aches in joints_______ Arthritis_______ Stiffness, limited movement_______ Pain, aches in muscles_______ Weakness or tiredness_______ TOTAL

Weight_______ Binge eating or drinking_______ Craving certain foods_______ Excessive weight_______ Compulsive eating_______ Water retention_______ Underweight_______ TOTAL

Other_______ Frequent illness_______ Frequent or urgent urination_______ Genital itch, discharge_______ TOTAL

________ Grand Total

Add up the numbers to arrive at a total for each section to arrive at the grand total.

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Candida QuestionnaireCheck the box corresponding to your health answer

A - HistoryHave you taken antibiotics for acne for yes - 35one month or longer? no - 0

Have you, at any time in your life, taken other antibiotics for respiratory, urinary, or other infections? (for 2 months or longer or yes - 6in shorter courses 4 or more times in a one-year period) no - 0

Have you ever taken an antibiotic drug, yes - 6even a single course? no - 0

Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis, or other problems affecting your yes - 25reproductive organs? no - 0

Have you been pregnant?2 or more times yes - 51 time yes - 3 no - 0Have you taken birth control pills?For more than 2 years? yes - 15For 6 months - 2 years? yes - 8 no - 0Have you taken prednisone or other cortisone-type drugs?For more than 2 weeks? yes - 15For 2 weeks or less? yes - 8 no - 0Does exposure to perfumes, insecticides, fabric shop odors, and other chemicals provoke:Moderate to severe symptoms? yes - 20Mild symptoms yes - 5 no - 0

Are your symptoms worse on damp, yes - 20muggy days or in moldy places? no - 0

Have you ever had athletes foot, ringworm, “jock itch” or other chronic fungus infections of the skin or nails, and have they been:Severe to persistent? yes - 20Mild to moderate? yes - 10 no - 0Do you crave the following?Sugar yes - 10Breads yes - 10Alcoholic beverages? yes - 10 no - 0Does tobacco smoke really bother you? yes - 10 no - 0

Total for section A ________

B - Major Symptoms

For each of your symptoms, check the appropriate answer in the point score column

Never 0 PointsOccasional or mild 3 pointsFrequent or moderately severe 6 pointsSevere and/or disabling 9 points

Fatigue or lethargy 0 3 6 9

Feeling of being “drained” 0 3 6 9

Poor memory 0 3 6 9

Feeling “spacey” or “unreal” 0 3 6 9

Inability to make decisions 0 3 6 9

Numbness, burning, or tingling 0 3 6 9

Insomnia 0 3 6 9

Muscle aches 0 3 6 9

Muscle weakness or paralysis 0 3 6 9

Pain and/or swelling in joints 0 3 6 9

Abdominal pain 0 3 6 9

Constipation 0 3 6 9

Diarrhea 0 3 6 9

Bloating, belching, intestinal gas 0 3 6 9

Vaginal burning, itching, discharge 0 3 6 9

Prostatitis 0 3 6 9

Impotence 0 3 6 9

Loss of sexual desire or feeling 0 3 6 9

Endometriosis or infertility 0 3 6 9

Cramps, menstrual irregularities 0 3 6 9

Attacks or anxiety or crying 0 3 6 9

Cold hands or feet/chilliness 0 3 6 9

Premenstrual tension 0 3 6 9

Shaking or irritable when hungry 0 3 6 9

Total for each column ___ ___ ___ ___

Total for section B _______

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C - Other Symptoms

Never 0 PointsOccasional or mild 3 pointsFrequent or moderately severe 6 pointsSevere and/or disabling 9 points

Drowsiness 0 3 6 9Irritability or jitteriness 0 3 6 9Lack of coordination 0 3 6 9Inability to concentrate 0 3 6 9Frequency of mood swings 0 3 6 9Headache 0 3 6 9Dizziness/loss of balance 0 3 6 9Pressure above ears, feeling of head swelling 0 3 6 9Tendency to bruise easily 0 3 6 9Chronic rashes or itching 0 3 6 9Numbness, tingling 0 3 6 9Indigestion or heartburn 0 3 6 9Food sensitivity or intolerance 0 3 6 9Mucus in stools 0 3 6 9Rectal itching 0 3 6 9Dry mouth or throat 0 3 6 9Rash or blisters in mouth 0 3 6 9Bad breath 0 3 6 9Foot, hair, or body odor not relieved by washing 0 3 6 9Nasal congestion/post-nasal drip 0 3 6 9Nasal itching 0 3 6 9Sore throat 0 3 6 9Laryngitis, loss of voice 0 3 6 9Cough or recurrent bronchitis 0 3 6 9Pain or tightness in chest 0 3 6 9Wheezing/shortness of breath 0 3 6 9Urinary frequency or urgency 0 3 6 9Burning on urination 0 3 6 9Spots in front of eyes/erratic vision 0 3 6 9Burning or tearing of eyes 0 3 6 9

Recurrent infections or fluid in ears 0 3 6 9

Ear pain or deafness 0 3 6 9

Total for each column ___ ___ ___ ___Total for section C _______

Total Scores

Part A _____________________

Part B _____________________

Part C _____________________

Grand Total Score ____________

Your grand total score will help you and your Nutritionist decide if your health problems are yeast connected.

Scores in women will run higher as 7 items apply exclusively to women while only 2 apply exclusively to men.

Women score 180+Men score 140+

Yeast-connected health problems are almost certainly present in women with scores over180, and in men with scores over 140.


Yeast-connected health problems are probably present in women with scores over 120 and in men with scores over 90.


Yeast-connected health problems are possibly present in women with scores over 60 and in men with scores over 40.

Women score less than 60Men score less than 40

Yeasts are less apt to cause health related problems in women with scores less than 60 and in men with scores less than 40.

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Carbohydrate Sensitivity Test

If the statement applies, write the number of points in the space provided. If it does not apply, leave the space blank.

_______ At a restaurant, I almost always eat too much bread, even before the meal is served. (2 points)

_______ If I have a breakfast containing carbohydrates, it is harder for me to control my eating for the rest of the day than it would be if I had coffee or nothing at all. (3 points)

_______ Once I start eating sweets, starches, or snack foods, I often have a difficult time stopping. (3 points)

_______ I would prefer to have an ordinary meal with dessert rather than have a gourmet meal that excludes it. (3 points)

_______ A meal of only meat and vegetables leaves me feeling unsatisfied. (3 points)

_______ If I’m feeling down, a snack of cake or cookies makes me feel better. (3 points)

_______ If potatoes, bread, pasta, or dessert are on the table, I will often skip eating vegetables or salad. (3 points)

_______ I sometimes have a hard time going to sleep without a bedtime snack. (3 points)

_______ At times I wake in the middle of the night and can’t go to sleep without a bedtime snack. (3 points)

_______ Now and then I think I am a secret eater. (3 points)

_______ I get tired and/or hungry in the midafternoon. (4 points)

_______ When I want to lose weight, I find it easier not to eat for most of the day than to try to eat several small low- calorie meals. (4 points)

_______ I get a sleepy, almost “drugged” feeling after eating a large meal containing bread, pasta, or potatoes and dessert, whereas I feel more energetic after a meal of only meat and salad. (4 points)

_______ When I am not eating, the sight of other people eating is sometimes irritating to me. (4 points)

_______ About an hour or two after eating a full meal that includes dessert, I sometimes want more of the dessert. (5 points)

_______ After finishing a full meal, I sometimes feel that I could go back and eat the whole meal again. (5 points)

_______ Before going to dinner at a friend’s house, I will sometimes eat something in case dinner is delayed. (5 points)

_______ Score

What your score indicates 21 or less: It is very unlikely that you are carbohydrate intolerant.

22-30: There is a possibility that you are carbohydrate intolerant.

31-44: There is a reasonable certainty that you are carbohydrate intolerant.

45-60: You are definitely carbohydrate intolerant.

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Nutrition Counseling Waiver and Release of Liability

I agree and understand that during and after participating in nutrition counseling from Nutritional Weight & Wellness, Inc.:

_____ 1. I authorize Nutritional Weight & Wellness Inc. to keep and secure files related to my nutrition counseling sessions at its offices.

_____ 2. I understand that Nutritional Weight & Wellness Inc. provides no guarantee or assurances that through nutrition counseling I will achieve my wellness goals, lose weight, or overcome or avoid health issues, such as cardiovascular disease or diabetes.

_____ 3. I assume all responsibility and any risks associated with the nutritional choices that I make. I agree to hold Nutritional Weight & Wellness, Inc. and its counselors harmless and release them from any liabilities associated with recommendations and information given by them to me relating to dietary changes or nutritional supplements. I specifically recognize and agree that I have been advised by Nutritional Weight & Wellness, Inc. that dietary changes and/or the taking of nutritional supplements may have differing effects on individuals. I understand that with respect to changes in my diet or in my nutritional practices it is recommended that I consult with my physician.

_____ 4. I understand that the nutritional counseling provided is not considered to be medical advice and that I am encouraged to continue to pursue medical care with my health care provider.

Having read and understood the above release and having had the opportunity to ask questions regarding the meaning and effect of this Waiver and Release of Liability, my signing is voluntary.

_______________ __________________________________ Date Signature of Participant

__________________________________ Printed Name of Participant

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