SHEILA WOLFSON, M.Ed., C.N.S.
|Send to firstname.lastname@example.org|
Client ______________ Date_________
1. Are there any foods you avoid for health reasons?
2. Do you have problems with: indigestion, belching gas, bloating?
- How is your appetite
- How is your thirst?
- What are your favorite foods?
- What are your least-liked foods?
- Do you enjoy eating?
- Do you feel that your diet is deficient in any way? How_________
- Do you feel your diet is excessive in any way?
4. Who cooks your food?
- If you do, do you enjoy cooking?
- Who does the shopping in your household?
- Where do you shop?
5. What is mealtime like in your household? (What & When )
- What were mealtimes like in your household growing up
breakfast lunch dinner
- Did you learn any food rules from your family?
6. Do feelings make you eat a certain way?________________________________________________ _________________________________________________________________________________ Does eating make you feel a certain way?_________________________________________________ _________________________________________________________________________________ 7. Describe your weight history._________________________________________________________ _________________________________________________________________________________ 8. Describe your eating history._________________________________________________________
HOW HAVE YOU FELT IN THE PAST 30 DAYS?
Sheila Wolfson, M.Ed., C.N.S.
0 Circle any of the following that apply to you.
|Nausea or vomiting||Itchy ears||Mood swings|
|Diarrhea||Earaches. ear infections||Anxiety, fear or nervousness|
|Constipation||Drainage from ears||Anger or irritability|
|Bloating||Ringing in ears||Depression|
|Belching or passing gas||Hearing loss||Headaches|
|Heartburn or indigestion||Watery or itchy eyes||Faintness|
|Fatigue. sluggishness||Swollen or reddened eyelids||Dizziness|
|Apathy. lethargy||Bags or dark circles under eyes||Insomnia|
|Hyperactivity||Blurred vision||Irregular or skipped heartbeat|
|Restlessness||Chest congestion||Rapid or pounding heartbeat|
|Pain or aches in joints||Asthma, bronchitis||Chest pain|
|Pain or aches in muscles||Shortness of breath||Varicose veins|
|Back pain||Difficulty breathing||Hemorrhoids|
|Foot or leg cramps||Stuffy nose||Poor memory|
|Stiffness||Hay fever||Poor concentration|
|Limitation of movement||Sneezing attacks||Poor physical coordination|
|Muscle weakness or tiredness||Excessive mucus formation||Difficulty making decisions|
|Slow wound healing||Chronic coughing||Stuttering or stammering|
|Bruise easily||Gagging||Slurred speech|
|Nail problems||Frequent need to clear throat||Binge eating|
|Acne||Sore throat||Binge drinking|
|Hives, rashes or dry skin||Hoarseness or loss of voice||Craving certain foods|
|Hair thinning or loss||Canker sores||Excessive weight|
|Flushing or hot Hashes||Swollen tongue, gums or lips||Compulsive eating|
|Excessive sweating||Discolored tongue, gums, lips||Underweight|
|Menstrual pain||Frequent illness||Water retention|
|Menstrual irregularity||Frequent or urgent urination||Cold hands and feet|
|PMS||Genital itch or discharge||Heavy menstrual bleeding|