How Well Do You Sleep? Daily Stress Level (Please Rate) Daily Energy Level (Please Rate) High Excellent How Long Do You Sleep? Moderately High Good Average Fair None Poor Do You Exercise? How Important is Religion/Spirituality Do You Drink Alcohol? to You and Your Family’s Life? What Type? Extremely Important How Much Per Week? How Often Per Week? Somewhat Important Do you Flush with Alcohol Intake? For How Long? Not At All Important Do You Use Recreational Drugs? Do You Smoke? Where have you lived and traveled? How Much Per Week? How Much Per Day? For How Many Years? Previous Surgery and Dates: Have You Been Diagnosed With: Do You Have or Wear: Appendectomy Date: ( / / ) Anemia Glasses Hysterectomy Date: ( / / ) Arthritis Contact lenses Tonsils/Adenoids Date: ( / / ) Asthma Hearing Aid(s) Breast biopsy Date: ( / / ) Bronchitis Dentures Back surgery Date: ( / / ) Cancer type: Pacemaker Knee surgery Date: ( / / ) Diabetes Artificial knee(s) Oral surgery Date: ( / / ) Epilepsy Artificial hip(s) Cesarean Section Date: ( / / ) Gallstones Other: Tubal Ligation/Vasectomy Date: ( / / ) Gout Other: Date: ( / / ) Heart Attack Other: Date: ( / / ) Heart Failure How Often Have You Taken Antibiotics? Other: Date: ( / / ) Heart Valve Problems <5 times >5times Hepatitis (Liver problem) Infancy/Childhood Previous Injuries and Dates: High Blood Pressure Teen Head Injury Date: ( / / ) High Cholesterol or Triglycerides Adult Neck injury Date: ( / / ) Irritable Bowel or Colitis Back injury Date: ( / / ) Kidney Stones How Often Have You Taken a Course of Bones Broken Date: ( / / ) Mononucleosis Oral Steroids? Plantar Fasciitis <5 times >5times Previous Car or Tramatic Injury: Pneumonia Infancy/Childhood Head Injury: Rheumatic Fever Teen Neck injury: Sleep Apnea Adult Back injury: Stroke Bones Broken: Thyroid Problems NAME: DOB:
How Well Do You Sleep? How Long Do You Sleep? Daily Stress Level (Please Rate) High Moderately High Average None Daily Energy Level (Please Rate) Excellent Good Fair Poor Do You Exercise? What Type? How Often Per Week? For How Long? How Important is Religion/Spirituality to You and Your Family’s Life? Extremely Important Somewhat Important Not At All Important Do You Drink Alcohol? How Much Per Week? Do you Flush with Alcohol Intake? Do You Use Recreational Drugs? How Much Per Week? Do You Smoke? How Much Per Day? For How Many Years? Where have you lived and traveled? Previous Surgery and Dates: Appendectomy Date: ( / / ) Hysterectomy Date: ( / / ) Tonsils/Adenoids Date: ( / / ) Breast biopsy Date: ( / / ) Back surgery Date: ( / / ) Knee surgery Date: ( / / ) Oral surgery Date: ( / / ) Cesarean Section Date: ( / / ) Tubal Ligation/Vasectomy Date: ( / / ) Other: Date: ( / / ) Other: Date: ( / / ) Other: Date: ( / / ) Previous Injuries and Dates: Head Injury Date: ( / / ) Neck injury Date: ( / / ) Back injury Date: ( / / ) Bones Broken Date: ( / / ) Previous Car or Tramatic Injury: Head Injury: Neck injury: Back injury: Bones Broken: Have You Been Diagnosed With: Anemia Arthritis Asthma Bronchitis Cancer type: Diabetes Epilepsy Gallstones Gout Heart Attack Heart Failure Heart Valve Problems Hepatitis (Liver problem) High Blood Pressure High Cholesterol or Triglycerides Irritable Bowel or Colitis Kidney Stones Mononucleosis Plantar Fasciitis Pneumonia Rheumatic Fever Sleep Apnea Stroke Thyroid Problems Do You Have or Wear: Glasses Contact lenses Hearing Aid(s) Dentures Pacemaker Artificial knee(s) Artificial hip(s) Other: How Often Have You Taken Antibiotics? <5 times >5times Infancy/Childhood Teen Adult How Often Have You Taken a Course of Oral Steroids? <5 times >5times Infancy/Childhood Teen Adult NAME: DOB:
Functional-Nutrition-Intake-Consent.docx