Physicians and Allied Health Professionals (list Below: Include Name, Specialty, Phone #) *
Current Health Problems (list and include date of onset). if none, enter "N/A" *
Past Medical History (list relevent information below with dates included). if none, enter "N/A"
Past Surgical History and Injuries (list below and include date). if none, enter "N/A" *
Medication (list all prescriptions and include Name, Dosage, Frequency and Date Started). if none, enter "N/A" *
Do you have any medication allergies? Please list. if none, enter "N/A"
Mother (if alive, age? if deceased, cause of death?) *
Mother Health Concerns (please list). if none, enter "N/A" *
Father (if alive, age? if deceased, cause of death?) *
Father Health Concerns (please list). if none, enter "N/A" *
if you checked any of the conditions on the previous question, please list who it was, what age, specific conditions, etc.) if not applicable, just enter "N/A" *
Currently occupation *
How many hours per day do you work? if not applicable, enter "N/A" *
Hours per week? if not applicable, enter "N/A" *
Length of time at current employer. if not applicable, enter "N/A" *
How many hours of sleep do you get each night (on average) on the weekdays? *
How many hours of sleep do you get each night (on average) on the weekdends? *
On average, how much coffee do you consume daily? (please note the number of drinks/cups per day) *
On average, how much tea do you consume daily? (please note the number of drinks/cups per day) *
On average, how much soda/pop (ex Coke) do you consume daily? (please note the number of drinks/cups per day) *
if yes (you smoker), how much do you smoke? (if not applicable, enter "N/A") *
if yes (ex-smoker), when did you quit? (if not applicable, enter "N/A") *
if yes, which ones? (if not applicable, enter "N/A") *
How much alcohol do you drink on average? (please provide # of drinks per day, # of drinks per week and # of drinks per month) *
Please include any other information below related to your stress management *
if you do resistance training, what's your routine? if not applicable, enter "N/A" *
Please enter the sports you participate in below (if applicable) and include whether you participate recreationally, competitively, or professionally. if not applicable, enter "N/A" *
Briefly describe any current medical or lifestyle issues you have and how they affect your diet and/or food choices (i.e., food allergies, vegetarian, lactose intolerant, IBS, diabetes, etc) *
Please list any supplements you take including dosage and frequency (if not applicable enter "N/A") *
if applicable, please describe the change and possible reasons. if not applicable, enter "N/A" *
if applicable, please describe your experience with the diets you've done in the past. if not applicable, enter "N/A" *
What are your current or future nutrition and/or weight-related goals? please describe. *
