Questionnaire

Date:

Name:

Email:

Address:

City:

State:

Zip:

Phone: ( )

Who referred you?

Age:

Male:

Female:

Height:

Weight:

Body Fat %:

Your Nutrition or Health Goal(s):

Chief Concern(s):

Surgeries and year(s) that you had them:

1.	When was your last doctor’s physical:
2.	When was your last doctor’s blood test (bring a copy):

Prescription Medications Usage or Over the Counter Medications: - Please check if you use any of the following:

1.	Antacids, Zantac, Pepcid AC, Rolaids, etc	10.	Aspirin/Acetaminophen
2.	Laxatives	11.	Cortisone/Anti-Inflammatories
3.	Ulcer Medications	12.	Cholesterol Lowering Medication
4.	Anti-diabetic/Insulin	13.	Heart Medications
5.	Relaxants/Sleeping Pills	14.	High Blood Pressure Medicine
6.	Thyroid	15.	Blood Thinners
7.	Chemotherapy	16.	Oral Contraceptives
8.	Radiation	17.	Hormones
9.	Antidepressants

18.	Antibiotic/Antifungal: Last time taken (Month-Year):
19.	Other medications not listed:
20.	List allergies to medications:
21.	List allergies to foods:
22.	List allergies to other things:

DIETARY HABITS:

Are you a vegetarian? Yes No
If yes, How long?	What percentage of your diet is RAW food? __________%

Describe the foods you normally eat:

Breakfast:

Lunch:

Dinner:

Snacks:

How times per week do you eat:

Check if you eat or drink:

1.	Candy	3.	Distilled Water
2.	Tap Water	4.	MRET Water
3.	Bottled Spring/Filtered Water	5.	Penta Water
4.	Reverse Osmosis Water	6.	Soft Water (Sodium or Potassium)

Please check: YES, Sometimes, Rarely or NO How often do you consume:

	Yes	Some-times	Rarely	No	Description
1.					Soda or carbonated beverages of any kind including carbonated water?
2.					White flour products?
3.					Fried foods?
4.					Fifty percent of your food in its raw form?
5.					Sugars other than fructose, sucanat, stevia, or raw organic honey?
6.					Artificial sweeteners?
7.					Red meat or pork?
8.					Tap water?
9.					Artificial colors, flavoring, MSG or preservatives (BHT, etc.)
10.					Hydrogenated or partially hydrogenated oils?
11.					Any tobacco products? How many years you used _____?
12.					Alcoholic beverages?
13.					Eight to ten glasses of water daily?
14.					At least six servings of whole grains daily? (Serving size: 1 piece of bread or ¾ c. oatmeal)
15.					At least three servings of fresh fruit daily? (Serving size is ½ c. chopped)
16.					At least three servings of vegetables daily? (Serving size is ½ c. chopped)
17.					Two to three servings of protein daily (eggs, raw nuts, legumes, beans, lean meats)?
18.					Two servings daily of dairy (low-fat milk, cottage cheese, yogurt, etc.)?
19.					One Tbsp. of flax seeds daily?
20.					Oils in the form of extra virgin olive oil and safflower or canola oil daily?
21.					Real butter as opposed to margarine?
22.					Mainly grains, some fruits and vegetables, a small amount of dairy and protein and sparingly fats, oils and sweets daily (according to the Eating Right Pyramid)?

How times per week on average do you Exercise: