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SHEILA WOLFSON, M.Ed., C.N.S. |
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Send to sheilaw@sheilawolfson.com | |||||||
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NUTRITION INTAKE
Client ______________ Date_________
1. Are there any foods you avoid for health reasons? 2. Do you have problems with: indigestion, belching gas, bloating?
3.. Eating
- 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 )
breakfast :
lunch: dinner:
- 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 |
Arthritis | Sinus problems | Confusion |
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 |
Sheila 072015