Holistic Nutrition Lifestyle Assessment

  • Holistic Nutrition Consultation

    Lifestyle Assessment Form – Bloom for Life!

  • Thank you for taking the time to fill out this questionnaire. Completion will commence our Holistic Nutrition session and allow me to better gauge your unique needs.  – Amanda Froelich

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  •   30 minutes or less 1 2 3 4 5 6 or more
    Driving
    Watching Television
    Reading
    In front of a computer
  • Medical History:

  • Family History

  •   F M S G O
    Allergies
    Arthritis
    Alcoholism
    Autoimmune Disease
    Cancer
    Diabetes
    Drug Abuse
    Gallbladder Issues
    Hypertension
    Intestinal Disease
    Kidney Dysfunction
    Mental Illness
    Osteoporosis
    Skin Conditions
    Ulcers
  • Females

  • Males

  • Dietary Habits:

  • How many times a day do you eat…

  •   1 2 3 4 5 6 7 8 or more
    Fruit
    Vegetables
    Whole Grains
    Protein
    Dairy Products
    Other:
  •   1 2 3
    Aluminum Pans
    Microwave
    Luncheon Meats
    Artificial Sweeteners
    Refined Foods
    Margarine
    Fried Foods
    Cigarettes
    Candy
    Fast Foods
  •   1 2 3 4 5 6 7 8 or more
    Tap water
    Coffee
    Tea
    Soft drinks (diet)
    Soft drinks (regular)
    Fruit juices (prepared)
    Fruit juices (fresh)
    Milk (1%, 2%, or whole)
    Milk (skim)
    Prepared vegetable juices
    Fresh vegetable juices
    Red wine
    White wine
    Beer
    Other alcoholic beverages
    Bottled or spring water
    Herbal tea
    Other
  • Client Statement:

  • By submitting this Lifestyle Assessment, I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnosis, treatment, or perscribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This form is being submitted voluntarily.

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