clean. green. healing. whole foods fuel.

junk·ie also junk·y  (jŭng′kē)
n. pl. junk·ies Slang

One who has an insatiable interest or devotion.

                                                                                                                                                                                                              Lakee Hesch . Holistic Nutrition Practitioner . 602.451.9950   

Today’s Date:______________________

 

 

Consent:

            I,________________________________, hereby acknowledge that I am seeking the services of Lakee Hesch, Holistic Nutrition Practitioner .  It is my understanding that Lakee is not diagnosing nor prescribing.  Any information or recommendations given to me are educational only and an aid for a path towards optimal health.

 

Confidential Client Information

 

 

Name:_________________________________________________________________________________

 

Address:________________________________________________________________________________

 

City:_________________________________         State:_____________________Zip:_______________

 

Home Phone:________________________         Cell Phone:__________________________________

 

E-Mail:__________________________________________________________________________________

 

Height:______________________________          Weight:_________________Age:________________

 

Blood Type:__________________________         Ethnicity:____________________________________

 

Birth Date:___________________________          Occupation:_________________________________

Did you eat anything green yesterday? If so, what? _______________________________________

How did you hear about us? _____________________________________________________________

Have you ever sought holistic health education? If so, what where/when? _________________

_________________________________________________________________________________________

Current Living Situation (i.e. spouse, children, roommates, parents, other relatives, etc.)

_________________________________________________________________________________________

How many hours per week do you work?__________________________________________________

 

What is your work schedule (i.e., days, nights, weekends, swing)?___________________________

_________________________________________________________________________________________

 

 

Is your work physical or do you sit for most of your work hours?_____________________________

Health History

Describe your current health concerns and what you are hoping to learn from nutritional counseling.  If you have a specific health condition, please describe it in detail including the first time you noticed or were diagnosed with your condition.  Please list any factors you suspect may have played a role in its onset and continuation.

 

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

How would you describe your current state of health? (circle one)

 

Excellent               Good              Average                     Fair                  Poor

 

What is your average energy level from 1 to 10? ( 1 is lowest) __________________________

 

Are you happy with your current weight? If not what is you ideal weight? ______________

 

 

 

 

 

 

Do you now, or have you ever had, any other health issues? (please circle all that apply)

 

Asthma

Diabetes

Irritable Bowel Disorder

Anorexia/Bulimia

Hemorrhoids

Kidney Stones

Chron’s Disease

High Blood Pressure

Low Blood Pressure

Compulsive Eating

High Cholesterol

Lupus

Anemia

Heart Disease

Migraine Headaches

Alcoholism

Diverticulitis

Obesity

Celiac

Eczema

Osteoporosis

Cancer

Fibromyalgia

Overweight

Arthritis

Gout

Stroke

Candida

Heartburn/Acid Reflux

Thyroid Disease (hyper or hypo)

Allergies

Hernia

Ulcer

Chronic Fatigue

Gallstones

Ulcerative Colitis

 

 

 

 

 

 

Other Conditions(please list):_______________________________________________________________

 

___________________________________________________________________________________________

 

Have you had any major surgeries?  Any organs removed (i.e., gall bladder, kidney, thyroid, appendix, tonsils, gastric bypass)?

 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Do you have any known allergies to food or medications?     (  )YES  (  )NO

If yes, please list medication or food and your reaction to it:______________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

 

List medications (drugs) you are currently taking, including aspirin, birth control or hormone therapy.  (Please give full name, strength, dosage, and how long you have been taking).

 

1.___________________________________________________________________________________

2.___________________________________________________________________________________

3.___________________________________________________________________________________

4.___________________________________________________________________________________

5.___________________________________________________________________________________

 

List vitamins, herbs, and nutritional supplements you are currently taking.  (Please give full name, strength, dosage, and how long you have been taking)

1.___________________________________________________________________________________

2.___________________________________________________________________________________

3.___________________________________________________________________________________

4.___________________________________________________________________________________

5.___________________________________________________________________________________

 

Do you exercise?       (  )YES         (  )NO       (  )Unable                  

 

Is your exercise level             (  )Mild                   (  )Moderate       (  )Strenuous

Do you sleep well?    (  )YES              (  )NO

How many hours nightly? ________________

 

 

 

What are your goals for your health?____________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

______________________________________________________________________________________

What is the most important thing you feel you should change about your diet to improve your health?

______________________________________________________________________________________

______________________________________________________________________________________

What three factors in life do you feel are most important to your daily health?

1._____________________________________________________________________________________

2._____________________________________________________________________________________

3._____________________________________________________________________________________

 

What do you feel your biggest obstacles are to challenge you from achieving your health/weight goals?

 

______________________________________________________________________________________

 

 

 

 

 

 

Eating/Food History

What did you eat yesterday?

Breakfast:____________________________________________________

 

Lunch: _______________________________________________________

 

Dinner: _______________________________________________________

 

Snacks: ______________________________________________________

 

Liquids: ______________________________________________________

 

 

 

Please describe your eating history in detail:  What did you eat as a child growing up in your family?  Compare that to your current eating habits.  How are they similar/different? (Use separate sheet if necessary)

 

________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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____________________________________________________________________________________________________________

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Are there any specific foods or classes of foods that you do not eat, either for personal health reasons or for religious/spiritual reasons?______________________________________________________________________________

_______________________________________________________________________________________________________

 

Are you a vegetarian?     (  )YES      (  )NO

   

If yes, what type?              (  )Ovo       (  )lacto-ovo                  (  )vegan

 

How many meals per week are from:

restaurants____________          Frozen or packaged(microwaved)_________freshly prepared at home_________

 

What are your favorite foods?_______________________________________________________________________________

____________________________________________________________________________________________________________

What foods do you dislike or refuse to eat?__________________________________________________________________

___________________________________________________________________________________________________________

 

Which of the following kitchen appliances do you own/use?

(   ) Blender

(   )  High Powered Blender (i.e., Vitamix, Blendtech, Ninja, Bullet, etc.)

(   )  Juicer

(   )  Food Processor

(   )  Crock Pot

(   )  Bread Machine

(   )  Dehydrator

 

 

Please list any other information, which you believe will be helpful in the evaluation of your health and eating habits. ____________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

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