nutrition junkie.
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? _________________
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Current Living Situation (i.e. spouse, children, roommates, parents, other relatives, etc.)
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How many hours per week do you work?__________________________________________________
What is your work schedule (i.e., days, nights, weekends, swing)?___________________________
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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.
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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):_______________________________________________________________
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Have you had any major surgeries? Any organs removed (i.e., gall bladder, kidney, thyroid, appendix, tonsils, gastric bypass)?
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Do you have any known allergies to food or medications? ( )YES ( )NO
If yes, please list medication or food and your reaction to it:______________________________________________
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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?____________________________________________________
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What is the most important thing you feel you should change about your diet to improve your health?
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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?
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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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Are there any specific foods or classes of foods that you do not eat, either for personal health reasons or for religious/spiritual reasons?______________________________________________________________________________
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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?_______________________________________________________________________________
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What foods do you dislike or refuse to eat?__________________________________________________________________
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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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