Print 3 Day Nutrition and Activity Journal

CLIENT FORMS

Confidential Health History, Intake and Evaluation

Name:

Date:

Address:

City:

State:

Zip:

Phone No. (best):

Alternative:

Email:

Birth date:

Birth Place:

Height:

Current Weight:

One Year Ago:

Body Frame (S,M,L):

Relationship Status:

Children and Ages:

Occupation:

Exercise/Recreation and # of times/week:

Do you sleep well?

How many hours:

How many times do you wake up during the night?

Please describe your main health concerns and goals:

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother and father?

Have any other family members had similar health concerns (describe)?

Please list all medicine or supplements you are currently taking:

Constipation/diarrhea/gas? Please explain:

Allergies or sensitivities? Please explain:

How are your moods in general? Do you experience more anxiety than you wish? Depression? Anger?

Describe any sources of stress in your life (work, family, relationships, financial, physical):

Dietary Habits and Choices

What role do sports and exercise play in your life?

What were your diet and family eating habits like growing up?

On a scale of 1 to 10, 1 being the worst and 10 being the best, describe your usual level of energy:

12345678910

What percentage of your food is home-cooked? Do you cook?

The most important thing I could do to improve my health is:

Anything else you would like to share?

Disclaimer of Liability

Sue Benun is not a physician or psychologist, and the scope of the consultation services does not include treatment or diagnosis of specific illnesses or disorders. If you, the client, suspect you may have an ailment or illness that may require medical attention, then you are encouraged to consult with a licensed physician without delay. Only a licensed physician can prescribe drugs. Any mention of drugs in the course of consulting is for the purpose of providing a complete history of drugs that the client is taking and not for Sue Benun to judge the appropriateness of the medication. Any change in prescription or dosage is a decision the client makes with his or her physician.

Wellness and the prevention of illness through the use of non-toxic, natural nutritional therapies to achieve optimal health is the focus of Sue Benun Nutrition. As a certified holistic nutrition consultant and wellness educator, Sue Benun educates, motivates and empowers clients to adopt a healthy diet and lifestyle.

By signing below, you acknowledge that you understand that Sue Benun is a Nutrition Consultant and not a physician, and that you should see a doctor if you think you have a medical condition.

Client’s Signature

Date

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