Initial Assessment Form


Personal Information
Full Name *
Full Name
DOB
DOB
Street, City, State, Zip
Phone
Phone
Chief Complaint(s) / Reasons for Visit
Nutrition and Medical Information
Have you ever had a nutrition consultation?
Do you currently follow a special diet or nutritional program?
Medications Currently taking including over the counter meds
Medication ----- Amount/day ----- Reason Taking and Other Comments
Supplements Currently taking including over the counter meds
Supplement & Brand ----- Amount/day ----- Reason Taking and Other Comments
Lab Test
Lifestyle and Eating Habits
Do you exercise? (what kind/frequency)
Did something trigger any changes in health?
Do you smoke?
Do you drink?
Do you have pets?
Are you exposed to exhaust, mold?
Do you use perfume or cologne?
Eating Behaviors
Please note factors that apply
Daily Stressors
Please rate 1 (low) to 10 (high)
Goals
Initial Symptom Survey
Fatigue (sluggish, tired)
Hyperactive (nervous energy)
Restless (can't relax or sit still)
Daytime Sleepiness
Insomnia at night
Malaise (feeling lousy)
Seizures
Two Day Typical Food Intake
Referred by
Date
Date
Date
Date
Date
Date
Depression