Nutrition Intake Form

Your Contact Information

Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Home Phone *

Work Phone *

Cell Phone *

Email Address *

How did you learn about our services? *

If applicable, who referred you to our services?

Nutritional and Health Goals

Please enter your other nutrition and health goals.

Please list your top 5 health concerns. *

Lifestyle

Occupation *

Business Travel *

Frequency *

Person responsible for cooking *

Food shopping *

How many times per week do you eat restaurant food?

Breakfast *

Lunch *

Dinner *

Fast Food *

Alcoholic drinks per week *

Do you currently smoke? *

Have you tried to quit?

Do you plan to quit?

List any previous diets *

What movement do you include in your daily routine? *

Type of movement / physical activity *

Rate your current stress level on a scale of 1 through 10 (10 being considerable stress) *

Have you experienced any significant stressful events during the past 6 months? If so, please provide details *

How do you cope with stress? *

How do you relax? *

Are you interested in learning relaxation techniques? *

Do you experience restful sleep? *

How many consecutive hours of sleep do you average each night? *

Health History

Your GP name and contact info (if we need to contact her /him) *

List all past surgeries and medical procedures: *

Please list any medical conditions, health concerns or any past illnesses. *

Please list any prescribed medication. *

Please list any vitamins, minerals, or natural/homeopathic remedies which you are currently taking and the frequency. *

Please list any food allergies. *

Do you experience any of the following:

Please list any other family history below.

Anthropometric Measurements:

Height:

Weight:

Body Fat %

BMI:

BMR:

WHR:

Weight CategoryUnderweightAdequateOverweightObese

Weight Changes:NoneIntentionalUnintentional

Details:

Nutrition Focused Physical Findings

Eating Disorder:

BulimiaPastPresent

AnorexiaPastPresent

BingingPastPresent

Caloric DeficitPastPresent

Emotional Assessment

Do you consider yourself a positive person? Why or why not? *

How does stress affect you and your life? *

Do you feel you have healthy relationships and boundaries? *

Do you feel you are holding onto any past experiences or resentments? *

Do you feel you have too many responsibilities? *

Do you feel anything is preventing you from healing or attaining your goals? *

Consent

Nutritional counseling is not intended as a diagnosis, treatment, prescription, or cure for any disease, mental or physical, and is not intended as a substitute for traditional medical care.

I fully understand that Ara Wiseman Nutrition & Healing are not medical doctors, and I am not here for medical diagnostic or treatment procedures.

It is my responsibility and decision to take any supplements or make any changes to my diet. It is also my responsibility to consult with my primary care practitioner.

I have carefully read this agreement and understand it to be a full and final release of all costs, claims, causes of action and damages of any kind arising from or in connection with Ara Wiseman Nutrition & Healing nutritional counseling services.

Date *

Signature *

By signing this form, you provide consent as indicated above.

Nutrition Intake Form

Your Contact Information

Nutritional and Health Goals

Lifestyle

Health History

Anthropometric Measurements:

Nutrition Focused Physical Findings

Emotional Assessment

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Contact

Ara Wiseman

Toronto, Ontario

(416) 876-8155

info@arawiseman.com