Nutrition Consultation Questionnaire Name First Last AgeOccupation (what are you doing in life and how do you feel about it?)Do you have supportive relationships in your life? Please describe.Purpose of our ConsultTell me about why we are meeting. What do you feel is the primary purpose?Relevant Medical HistoryPlease list/describe any medical diagnoses or procedures I should be aware of.If applicable, have there been any inconsistencies with your menstrual cycle? If yes, please describe.Please list your current medications & supplements:Please list/describe any mental health concerns should I be aware of (i.e. depression, anxiety, OCD, PTSD)?Have you ever worked with a dietitian/nutritionist? If yes, tell me about your experience.Digestive HealthHave you ever received a gastrointestinal (GI) diagnoses? If yes, please describe:Did you have any GI issues as child or adolescent? If yes, please describe:Do you have any food allergies or intolerances? If yes, please describe.Gastrointestinal symptomsOn a scale of 1-10 (10 = terrible, 1=non-existent) please state a number that identifies the level intensity of the following symptoms:Gas12345678910Nausea12345678910Constipation12345678910Reflux12345678910Bloating12345678910Diarrhea12345678910Abdominal Pain12345678910Incomplete emptying12345678910Relevant Family HistoryShare with me any family/spouse dynamics you feel are important for me to know/understand.What was food like in your house growing up? What is it like now? Does anyone in your family have a history of dieting, disordered eating, or eating disorders? Other chronic illnesses?Appetite & Eating PatternsHow many meals do you eat in a day?Do you tend to skip meals? If yes which ones do you skip and why?Do you ever find your self uncomfortably hungry or uncomfortably full? If yes, please describe:When you are overwhelmed, or life gets busy, do you neglect your eating habits?YesNoIf yes, please describe:Do you feel that your life/schedule conflicts with nourishing your body in the way you’d like to?YesNoPlease describe.Do you eat and multi-task (i.e. read, watch TV, drive)?YesNoPlease describe.Do you feel you eat particularly fast or slow? Please describe:Do you like to cook? Who does the grocery shopping? Who prepares the food at home?Dietary IntakePlease list the usual time and typical daily intake for each meal in recent weeks. BreakfastLunch:Dinner:Snacks:What foods do you love?What foods do you dislike?Are there any foods that you fear or feel like binge foods for you?Are there any foods that feel “safe” to you?Does your diet have a lot of variety or does it tend to be the same from day to day?Physical ActivityHave you ever had a consistent exercise routine?YesNoIf yes, tell me about your past exercise habits/relationship to exercise:Tell me about your current exercise habits/relationship to exercise:WeightYou can leave this section blank if you prefer or if it feels uncomfortable and we can discuss it in session together.Height:Current Weight:Average weight for the past 2 to 3 years?When were you last at that weight?Highest adult weight? How old were you?Lowest adult weight? How old were you?Have you lost or gained weight recently? How much? What was the time frame?Do you weigh your self? How often?How do you currently feel about your body?Strongly DislikeDislikeSlightly SatisfiedSatisfiedVery SatisfiedWorking TogetherWhat are you hoping to accomplish through our sessions together? This iframe contains the logic required to handle Ajax powered Gravity Forms.