Health Assessment Questionnaire Your Responses Will Remain Confidential CLIENT INFORMATIONName(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth(Required) Month Day Year HEALTH HISTORYWhat medical concerns do you have at the present time?(Required) Cancer Diabetes Heart Disease High Cholesterol High Blood Pressure Osteoporosis Thyroid Disorder Seizure Disorder Other Other Medical Concers(Required)Please describe: Do you have any blood relatives with the following conditions:(Required) Cancer Diabetes Heart Disease High Cholesterol High Blood Pressure Osteoporosis Thyroid Disorder Seizure Disorder Other Other Medical Conditions(Required)Please describe: Do you have complaints about any of the following:(Required) Appetite Issues (excessive or loss of appetite) Bleeding Gums Bruising Difficulty Chewing or Swallowing Constipation Diarrhea Edema Indigestion Menstrual Issues Low Light Vision Issues Sudden Weight Change Stress Other Other Complaints(Required)Please describe: Do you now, or have you ever, used tobacco in any form? Have you recently stopped smoking?(Required)Please explain: Do you enjoy physical activity?(Required) Yes No List any food allergies or intolerances:(Required) List any current prescription drugs:(Required) List any current non-prescription drugs or supplements.(Required)(Responses are Confidential) DIET HISTORYDo you follow a special dietary plan, such as, low cholesterol, kosher, vegetarian?(Required) Do you have any problems purchasing food that you want to buy?(Required) Are there certain foods that you do not, or cannot eat?(Required) Do you eat at regular times each day?(Required) Yes No Varies Daily How many times a day do you eat?(Required) Please identify any favorite foods:(Required) Do you drink alcohol? If yes, how much per week?(Required) In order to tailor your counseling experience to your needs, it would be useful to know your expectations. Please check one or more of the following to indicate the amount of structure you believe would help you to meet your needs and what goals or health changes you would like to make?(Required) Improve my eating habits Learn to manage my weight Improve my activity level Improve my cholesterol / triglyceride levels Other Other Expectations(Required)Please describe: Please add any additional information you feel may be relevant to understanding your Nutritional Health(Required) NUTRITIONAL EDUCATION INTERESTSWhat information would you like from your counsler?(Required) Supermarket Shopping Tour Weight Management Healthy Food Preparation Fiber Food Label Reading Dinning Out Portion Size Eating Less Fat Walking Program Exercise Alcohol Calories Meal Planning Snack Foods Other Other Information(Required)Please describe: MISCELLANEOUSSome of the following questions may seem irrelevant, but may be critical in the development of a complete and accurate assessment.What is your occupation? If retired, what was your occupation?(Required) How many people live in your household? (please list ages)(Required) Who prepares most of the meals in your home?(Required) You Your Spouse Both Other List who?(Required) Who does most of the shopping?(Required) You Your Spouse Both Other List who?(Required) How often do you dine out at restaurants?(Required) Never 1 Time 2 Times 3 Times 4 Times 5 Times 6 Times 7 Times 8 Times 9 Times 10 or more If yes, at what restaurants?(Required) PhoneThis field is for validation purposes and should be left unchanged.
