NAME: __________________________________________________________________DATE: _______________________________
ADDRESS: ___________________________________________________________________________________________________
CITY: ___________________________________________________________ STATE: __________________ ZIP: _______________
HOME PHONE: _____________________________WORK PHONE: __________________CELL PHONE:_______________________
EMAIL:_______________________________________________________________________________________________________
DATE OF BIRTH: _______________________________WEIGHT: _____________ HEIGHT:________________________
Reason for consultation and/or goals: _______________________________________________________________________________
Do you smoke?___________ Drink alcohol? _______ How much/when?__________________________________________________
Do you drink caffeine every morning?_______________________________________________________________________________
Do you have food allergies, restrictions, or sensitivities? ________________________________________________________________
Describe your daily energy levels: __________________________________________________________________________________
Do you get noticeably irritable, light-headed, or weak if you haven't eaten in a while? __________________________________________
Do you crave certain foods? ____________ If so, which foods and when?___________________________________________________
Do you crave any of the following? ___ Sugar ___
Meat Fat ___ Chocolate ___ Fish ___ Alcohol ___ Desserts ___ Milk ___
Bread
___ Fried foods ___ Other
____________________________________________
Do you take any nutritional
supplements or vitamins? _____ If so, which ones? (be specific.
Attach sheets if necessary)
_____________________________________________________________________________________________________________
Which prescription and over the counter
medications do you take regularly?
_________________________________________________
_____________________________________________________________________________________________________________
Which oils do you
use/consume?
___ Butter ___ Peanut Oil ___ Canola ___
Margarine ___ Corn Oil ___ Sun/Safflower ___ Olive Oil
___ Crisco ___ Mayonnaise ___ Coconut Oil ___ Vegetable Oil ___ Flaxseed Oil ___ Soybean Oil ___ Other________________
Do you eat primarily organic fruits, vegetables and dairy products?________________________________________________________
How many bowel movements do you have a day? _____________________________________________________________________
Rank your skin without lotion: ___ Very Dry ___ Dry ___ Normal ___ Oily ___ Combination
Please check off any of the following that pertain to you (past or present ? please mark present conditions with a P next to it):
| ___
Acne ___ Difficulty loosing weight ___ Kidney stones ___ Addiction (alcohol, drugs) ___ Difficulty gaining weight ___ Liver problems ___ Anemia ___ Emotional problems (instability or sensitivity) ___ Loose stools ___ Anorexia ___ Emphysema ___ Memory loss or confusion ___ Anxiety or nervousness ___ Fainting ___ Nails, poor growth ___ Arthritis (Rheumatoid or Osteo) ___ Gall bladder problems ___ Panic attacks ___ Bladder infections (Cystitis) ___ Gout | ___ Parasites ___ Bloating, gas or indigestion ___ Hair loss or poor hair growth ___ Pregnant or nursing mother ___ Blood Sugar problems ___ Headaches ___ Respiratory problems ___ Bronchitis ___ Heart disease or problems ___ Ringing in ears ___ Cancer ___ Heartburn ___ Seizures ___ Colds or flu (frequent) ___ Hemorrhoids ___ Severe mood swings ___ Cold Sores ___ Herpes simplex or type II ___ Skin conditions ___ Chronic fatigue | ___ High blood
pressure ___ Stroke ___ Constipation ___ High cholesterol ___ Suicidal tendencies ___ Dandruff ___ HIV ___ Thyroid condition ___ Depression ___ Hot flashes ___ Ulcer ___ Diabetes I (insulin dependent) ___ Hypoglycemia ___ Yeast infections ___ Diabetes II (adult onset) ___ Insomnia ___ Multiple chemical sensitivity ___ Diarrhea ___ Intestinal problems |
| Women: Please check
all that pertain: ___ PMS ___ Irregular periods ___ Painful periods ___ Loss of periods ___ Birth control pills ___ Menopause ___ Painful intercourse ___ Children ___ Hysterectomy | Men: Please check all
that
pertain: ___ Frequent urination ___ Difficulty urinating ___ Difficulty with erection ___ Loss of libido ___ Prostate enlargement |
Please list any disease, illness, or
ailments in your immediate family (i.e.
mother-breast cancer, father-type II diabetic, grandfather-heart
disease).
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Personal weight loss history: How many
diets have you been on? _____ Which
ones? _________________________________________
What were your results? _______________________________________________________________________________________
How is your dental health?
______________________________________________________________________________________
Have you had silver dental fillings?
______________ How many?_______________
Have they been removed? _____________________
Do you use environmentally friendly
household products?
______________________________________________________________
Do you exercise? _________ If so, what kind?
_______________________________________________________________________
How often: Since when?
________________________________________________________________________________________
Please rate the following:
Daily energy level: ___ Excellent ___ Good ___ Fair ___ Poor
Energy level after exercise: ___
Excellent ___ Good ___ Fair ___ Poor
Daily stress level: ___ Very
High ___ High ___ Moderate ___ Low ___ None
Do you have a support system of family
and friends? ___________________________________________
General enjoyment of life: ___
Excellent ___ Good ___ Fair ___ Poor
How many hours do you sleep?
______ Do you sleep throughout the
night?_____ Do you wake up
without an alarm? _____
Do
you wake up feeling rested? ______ Do you fall asleep within 15 minutes?____
Please describe any health concerns you
think are important: ____________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
By
signing below, you acknowledge that any dietary or supplemental
suggestions made by. Susan Mudd, are entirely nutritional in nature,
and are not intended as the diagnosis, cure or treatment for any
disease or ailment. You also acknowledge that your physician is your
primary health care provider, and is responsible for supervising all
changes in diet and nutrient intake that you make.
Signed: _______________________________________________________ Date: __________________________________________