Health Questionnaire - Nutrition Assessment

1 Health Questionnaire - Nutrition AssessmentClient InformationQuestions with asterisk (*) are required. NOTE: Do not copy/paste answers into any form fields, simply type in your responses. Donot use the enter/return key when typing in form 's Date:Appointment Date:Please select the location of your appointment: St. Paul Wayzata North Oaks Lakeville Maple Grove Mendota Heights Eden PrairieNutritionist:Client First Name:Client Middle Initial:Client Last Name:Date of Birth:Age:Gender:Parent or Guardian Name (if client is a minor)Address:City:State:Zip:Phone (Primary):This phone number is your Mobile Home WorkPhone (Secondary):This phone number is your Mobile Home WorkEmail:HeightWeight: Health concerns and goals for consultation:Are these the Health concerns you verified with Blue Cross Blue Shield?

2 Yes NoIf no, what Health concerns did you verify with Blue Cross Blue Shield?For follow-up, which is the best way to reach you? Phone EmailCan we leave a message on your primary phone? Yes NoHealth Questionnaire - Nutrition Assessment - Page 2 Client Insurance FormWe are in-network providers of Blue Cross Blue Shield of Minnesota. If you are a Blue Cross Blue Shield member, we can submityour insurance claim if you complete the insurance information (below) and present your current insurance card and photo ID on theday of your appointmentIt is your responsibility to verify insurance coverage and benefits through your Blue Cross Blue Shield member servicesrepresentative. This number can be found on the back of your card. You will be responsible for any non-covered NOTE: Phone and Skype appointments are not covered by Blue Cross Blue Shield of Minnesota.

3 DO NOT fill outthis insurance page if your appointment will be conducted via phone or you contacted your Blue Cross Blue Shield member services department to verify coverage? Yes NoDo you need a referral? Yes NoIf yes, did you receive a referral from your physician?If you would like us to bill Blue Cross Blue Shield of Minnesota please complete the information below:Please note: it is your responsibility to verify insurance coverage and benefits. You are responsible for any charges not covered byyour First Name:Client Middle Initial:Client Last Name:Client Date of Birth:Gender:Address:City:State:Zip:Prim ary Insurance InformationMember or Policy Holder's Name (if different than client)Social Security Number:Insurance ID#:Two Digit Member #:Group Number:Member or Policy Holder's Date of Birth (if different thanclient):Relationship to Client:I authorize the release of any medical or other information necessary to process this claim.

4 I also request payment of medicalbenefits from either a government or non-government source to Nutritional Weight and Wellness (NWW). I authorize NWW toinitiate a complaint to the Insurance Commissioner on my behalf. I understand and agree that regardless of my insurance status, I amultimately responsible for the balance of my account for any professional services rendered. I further understand that I will be legallyresponsible for all collection costs involved with the collection of this account including all court costs, reasonable attorney fees andall other expenses incurred with collection if I default on this agreement. In addition, if I issue a check that is returned by the bankfor non-sufficient funds, I understand I will be charged for $ for each returned check. I certify this information is true andcorrect to the best of my agree with the above terms.

5 Date:By signing your name below, you certify that you have read and agree to the terms listed above. Member's Signature: Health Questionnaire - Nutrition Assessment - Page 3 Health HistoryPlease check any that apply to you (past or present)PastPresentPastPresentAcneHeadac hesADD / ADHDH eart diseaseAddiction (alcoholor drugs)Heartburn, AcidRefluxAllergiesHemorrhoidsAnemiaHerp es simplexAnorexia orBulimiaHigh bloodpressureAnxiety ornervousnessHigh cholesterolArthritisHIVA sthmaHot flashesBed wettingHypoglycemiaBladder infectionsInsomniaBloating, gasIntestinal problemsBlood sugarproblemsKidney stonesBronchitisLiver problemsCancerMemory loss orconfusionCeliac diseaseNails, poor growthColds or flu(frequent)Nails, white spotsCold soresOsteopenia/OsteoporosisChronic fatiguePanic attacksConstipationParasitesCradle capPregnant/nursingmotherDandruffPsorias isDepressionRespiratoryproblemsDiabetes (Type I)

6 Ring in earsDiabetes (Type II)SeizuresDiarrheaSevere mood swingsDifficulty losingweightSkin conditionsDifficulty gainingweightSpider VeinsEar infectionsStomach AchesEczemaStrokeEmotionalinstability orsensitivitySuicidal tendenciesEmphysemaThyroid conditionFaintingUlcerGall bladderproblemsVaricose VeinsGoutYeast infectionsHair loss or poorhair growthHealth Questionnaire - Nutrition Assessment - Page 4 Health HistoryCholesterol:Blood Pressure:Women: please check any that pertain PMS Irregular periods Painful periods Loss of periods Birth control pills (past or present use) Loss of libido Menopause Painful intercourse Hysterectomy ChildrenIf children, how many:Ages:Men: please check any that pertain Frequent urination Difficulty with urination Difficulty with erections Loss of libido Prostate enlargementIf Appointment is for your child:Describe concentration, activity level, and behavior:List any behavior issues:Diet ReviewDescribe a typical day's meals (include all foods eaten, drinks, and times consumed).

7 Be as specific as you :Usual time:Lunch:Usual time:Dinner:Usual time:Snacks:Usual time(s):How many times do you usually eat per day?Do you drink?If yeshow many 8 oz. per day?WaterCoffeeSodaFruit juiceTeaIf you drink tea, what type:Do you drink alcohol? Yes NoIf yes, how many drinks per day/week/month? Health Questionnaire - Nutrition Assessment - Page 5 Diet ReviewDo you get noticeably irritable, light-headed, or weak if you haven t eaten in a while? Yes NoDo you often skip meals? Yes NoIf yes, which do you most commonly skip?What time(s) of the day are you most hungry?Do you crave (check all that apply): Sugar Chocolate Desserts Fried foods Meat Milk Fat Alcohol Bread OtherIf other, please list:Do you consume (check all that apply): Butter Margarine Olive oil Coconut oil Soybean oil Peanut oil Corn oil Crisco Vegetable oil Canola oil Mayonnaise OtherIf other, please list:What are your favorite foods?

8 What foods do you strongly dislike?Are you currently under a physician s care for a chronic Health problem that requires continuous monitoring? Yes NoIf yes, please explain:Do you take any nutritional supplements or vitamins? If yes, please list: (Please bring your supplements to yourappointment so that your nutritionist knows the amount and type of nutrients you are currently taking.)Please list your current medications and the Health conditions for which you are taking themMedicationHealth ConditionAntibiotic use: Less than once ayear More than 2 times peryear Hardly ever NeverReason for antibiotic use: Health Questionnaire - Nutrition Assessment - Page 6 Diet ReviewSteroid use (Cortisone or Prednisone) Frequent Rare NeverPlease list any disease, illness, or ailments in your immediate feel free to expand on any concerns you feel are relevant to your you sensitive to any of the following foods?

9 Please check all that apply. Gluten Soy Nuts Other DairyIf other, please expain:Do you have a family history of addiction? Alcohol Drugs or Medications Food TobaccoLifestyle FactorsOccupation:Work Hours:Do you exercise? Yes NoIf yes, what kind?How frequently do you exercise?Please rate the following:Daily energy level: Excellent Good Fair PoorDaily stress level: Very high High Moderate Low NoneEnergy after exercise: Excellent Good Fair Poor Not applicableGeneral enjoyment of life: Excellent Good Fair PoorDo others consider you: Inactive Active Very activeAre you: Often tired Occasionally tired Rarely tiredHow much sleep do you get each night on average?Any problems sleeping?Do you smoke? Yes NoHealth Questionnaire - Nutrition Assessment - Page 7 Lifestyle FactorsHave you recently quit smoking?

10 Yes NoDoes exposure to perfumes, insecticides, fabric shop odors, and other chemicals provoke: Moderate to severe symptoms Mild symptoms No symptomsHow is your dental Health ? Good Fair PoorHow often do you have bowel movements?How often do you urinate?How often do you eat out?Which restaurants?Do you eat: Alone With friends With spouse/significant otherIf weight loss is one of your goals, please complete the following questions. If weight loss is not one of your goals, please continueto the next page using the button at the bottom of the pageDo you feel you ve always had a weight problem? Yes NoIf yes, around what age did you first notice that you had gained weight?What do you feel your weight gain was caused by?What diets have you tried in the past?Have you ever had any Health problems as a result of dieting?