THRIVE Center For ADHD and Comprehensive Mental Health ...



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Instructions for your First Nutrition Consultation

Thank you for giving thoughtful consideration as you complete the nutrition questionnaire. This will take 30-45 minutes to complete, not including the 3-day food diary.

This questionnaire may be completed on the computer in Microsoft Word or another similar word processing program.

✓ Click inside of the grey box       and type answers directly into the form.

✓ Once completed, please email questionnaire to your practitioner at least 3 days BEFORE your appointment.

Required for your First Visit

✓ Completed questionnaire, including the 3-day food diary

✓ Any labs, blood tests or other pertinent information you think may be helpful.

The THRIVE Center’s fax number is 443-276-6640.

✓ Any pharmaceuticals, over-the-counter drugs, and/or supplements in their original containers.

Items requiring refrigeration may be left at home. Please make sure you write down the brand and dosage.

Instructions for Completing the 3-Day Food Diary

| | | |

|Record information as soon as possible after the food |Do not change your eating behaviors at this time |Describe the food or beverage being consumed, i.e., |

|has been consumed, including all beverages, even |unless your doctor advises you to. The purpose of this|milk (whole, 2%, nonfat); bread (whole wheat, white, |

|water. |food log is to analyze your present eating habits. |buttered); chicken (boneless, skinless, fried, baked),|

| | |etc. |

| | | |

|Record the amount of each food consumed using standard|Include added items and/or garnishes. For example: |Make a note of any feelings/thoughts when the food is |

|measurements such as, 8 ounces; ½ cup, 1 tablespoon, |black tea with 1 teaspoon of sugar; baked white potato|consumed. |

|etc. |with 2 teaspoons of butter, etc. |For example: famished; satisfied after dinner; feeling|

| | |stressed; eating on the go, etc. |

If you have any questions, please contact us.

Nutrition Questionnaire

Please allow 30-45 minutes to complete most of this questionnaire. The 3-day diet requires you to record your food and beverage intake over a 3-day period. Please answer the questions as thoroughly as possible to ensure we make the best assessment and develop a plan for supporting your health and wellness goals. Your answers to personal questions such as relationship status, religion, etc. are important and provide helpful context for establishing a productive partnership with you. With that being said, please answer only the questions you feel comfortable answering.

Basic Information

Today’s Date:      

|Contact Information |

|Name: |      |Address: |      |

|Home phone: |      |Work phone: |      |

|Mobile phone: |      |Email address: |      |

|Preferred contact |      |Best time(s) of day |      |

|method: | |to reach you: | |

|Emergency Contact |

|Name: |      |Relationship: |      |Phone: |      |

|Occupation & Interests |

|Occupation: |      |How long: |      |Satisfied (1-10)? |      |

|What are your interests & passions? |      |

|Demographics |

|Age: |

|Status: |      |Partner’s Name: |      |Partner’s Gender: |      |

|Personal Information |

|Religion: |      |Education: |      |

|Who do you share your home with? |      |

|(Persons or animals) | |

What types of health practitioners are you currently working with?

     

What are your primary reasons for seeking nutrition counseling?

1.      

2.      

3.      

Medical Information

| |      |Physician’s Office Number: |      |

|Name of Primary Care Physician & Address| | | |

| | |Physician’s Fax Number: |      |

|What health concerns did you experience as a child? |

|      |

|What health concerns have you experienced as an adult? |

|      |

|Are you part of a recovery program?       If so, which one?       |

| |

|Do you have any allergies to foods, medications, chemicals, and/or other environmental substances?       |

|If so, to which ones?       |

| |

|What is your typical reaction and how severe is it (1-10, 10 being most severe)? |

|      |

|What operations or surgical procedures have you undergone, and when? |

|      |

|Have you ever been hospitalized for reasons other than operations and/or surgical procedures?       |

|If yes, when, and for what reason(s)?       |

| |

|Have you ever had a major chemical exposure?       |

|If so, when?       |

|Where and when have you lived or traveled outside of the U.S. and Canada? |

|      |

|Has anything surfaced during a recent medical test, lab work, or doctor’s visit that you would like to report? |

|      |

|Do you experience pain or discomfort in any area of your body? |

| |

|Yes No |

|If yes, using the models to the left, please indicate the location of the |

|discomfort by using the symbol that best describes the feeling: |

| |

|X X Sharp/stabbing P P Pins & Needles |

|N N Numbness D D Dull/Aching |

|Do you have any difficulty with: |

| |

|Walking Sitting Standing Driving |

Medications & Supplements

|Past and Current Medications (Over the Counter and Prescription) |

|Name |Dosage |Frequency |Length of Time |Reason for Taking |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|Are you sensitive to low levels of medication(s) and/or caffeine? |      |

|Current Dietary or Herbal Supplements |

|Name |Brand |Dosage |Frequency |Length of Time |Reason for Taking |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

Family History

|Relationship |Alive/Deceased |Present Health or Cause of Death |

|Father |      |      |

|Mother |      |      |

|Brothers |      |      |

|Sisters |      |      |

|Maternal Grandmother |      |      |

|Maternal Grandfather |      |      |

|Paternal Grandmother |      |      |

|Paternal Grandfather |      |      |

|Children & ages |      |      |

For Women

|Pregnancies (please include losses/terminations) |

|Year |Vaginal/C Section |Sex |Complications/ Other Things You Want to Mention |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

Please check either YES or NO for the following questions:

Are you currently pregnant? YES NO Are you actively trying to conceive? YES NO

Are you breastfeeding? YES NO

Are you aware that you should inform your practitioner if you decide to conceive or if you become pregnant? YES NO

Review of Body Systems

Please place an “X” next to anything you are currently experiencing. Use a “P” to mark issues you previously but no longer have.

Please provide short answers to items with a question mark.

|Head |Female Reproductive |Gastrointestinal |Cardiovascular |

|      seizure |Breasts |      bad breath |      low blood pressure |

|      headache |      tenderness |      bloating/gas |      high blood pressure |

|      migraines |      abnormalities, lumps |      pain/cramping |      high cholesterol |

| |      discharge |      nausea |      heart attack |

|Eyes/Ears/Nose |Perform self-breast exams (Y/N)?       |      constipation |      heart palpitations |

|      vision loss |Genitals |      diarrhea |      chest pain |

|      corrective lenses |      vaginal discharge |      irritable bowel |      varicose/spider veins |

|      eye redness |      yeast infections |      colitis |      cold hands and feet |

|      eye discharge |      pelvic pain or masses |      variable bowel habits |      stroke |

|      eye/ear infection |Abnormal pap, resulting in action?      |      undigested food in stool |      clotting disorder |

|      hearing loss |Menses |      blood in stool |      bruise easily |

|      ringing in the ears |Date of last menses:       |      ulcers | |

|      ear discharge/itching |Length of menses       days |      hemorrhoids |Endocrine |

|      pain |      painful cramps |      liver/gallbladder issues |      low energy level |

|      nosebleed |      bleeding between cycles |      acid reflux/GERD |      hypothyroid (low) |

|      nasal congestion |      not menstruating |Bowel movements |      hyperthyroid (high) |

| |      fibroids |# per day       OR |      low blood sugar |

|Neck and Throat |      endometriosis |# per week       |      diabetes |

|      pain |      PCOS |Quality? | |

|      lump |Menopausal women |      pebbly |Skin |

|      enlarged thyroid |      menopausal symptoms |      fully formed |      eczema |

|      stiffness |      vaginal dryness |      soft & largely unformed |      rash |

|      tonsillitis |      hormone replacement therapy |      loose & unformed |      dry skin |

| |      osteoporosis | |      sensitive skin |

|Male Reproductive | |Respiratory |      acne |

|      difficulty with urination |Male and Female |      congestion |      itching |

|      benign prostatic hypertrophy |Sexually transmitted disease? |      asthma |      bruise easily |

|      pain/swelling in testicles or |      |      cough |      nail problems |

|prostate |Birth control (Y/N)?       |      difficulty breathing |      hair quality changes |

|      vasectomy |If Y, what form?       |      sinus pain/ or inflammation |      slow wound healing |

|      erectile insufficiency |      low libido |      tuberculosis | |

|      low sperm count |      painful intercourse/orgasm | |Musculoskeletal |

|      poor sperm motility | |Urinary |      muscle pain |

| |Neuro-Psychiatric |# of urinations per day?       |      arthritis/joint pain |

|Allergies & Immunologic |      anxiety |Color of urine?       |      stiffness |

|      respiratory allergies |      bipolar |      urinary tract infection |      gout |

|      immune disorder |      depression |      kidney infection |      back ache/pain |

|      frequent colds or flu |      AD/HD |      kidney stones |      mobility restrictions |

|      seasonal allergies |      mental fogginess and/or |      swelling | |

|Allergic to: |sluggishness |      incontinence |Lymph Nodes |

|      pet dander |      abnormal physical movements |      urgency |      congestion |

|      dust/mold |Other mental diagnosis? |      frequency |      swollen |

|      pollen/ragweed |      |      pain on urination |      painful |

|      trees/grass | |      blood in urine | |

|      food allergies | |      abnormal odor |Other |

|      food sensitivities | |      dark circles under eyes |      |

|      Celiac disease | | |      |

Lifestyle

|Physical Activity |

|Food/Drink |Frequency |Comments |

| |Monthly |Weekly |Daily |Multiple Times a Day| |

| | | | | |What type(s)? |

|Cardio type exercise | | | | |      |

| | | | | |What type(s)? |

|Strength building exercise | | | | |      |

| | | | | |What type(s)? |

|Stretching, meditation, | | | | |      |

|yoga activity | | | | | |

| | |

|How would you categorize your activity level? |Sedentary Mildly Active Moderately Active |

| | |

| |Very Active Intensely Active |

|Lifestyle |

| |Frequency |Comments |

| |Monthly |Weekly |Daily |Multiple Times a Day| |

| | | | | |      |

|Socializing with Friends | | | | | |

| | | | | |What type(s)? |

|Relaxation | | | | |      |

| | | | | |What type(s)? |

|Self-Pampering | | | | |      |

| | | | | |What type(s)? |

|Tobacco | | | | |      |

| | | | | |What type(s)? |

|Recreational Drugs | | | | |      |

| | | | | |      |

|Teeth Flossing | | | | | |

|Sleep |

|What time are you typically in bed? |      |

|What time do you fall asleep? |      |

|Typical hours asleep? |      |

|# of times you awaken during the night? |      |

|Reason(s) why you wake during the night? |      |

|Do you feel rested upon rising? |      |

|Stress |

|On a scale of 1-10, with 1 being low and 10 being high, how stressful are the following: |

|Work |      |

| |      |

|What do you believe you can do to make a difference in your current health | |

|status? | |

| |      |

|What 1-2 key steps have you already taken? | |

| | |

|When feeling stressed, do you: |have more of an appetite have less of an appetite |

|Moods You Experience Frequently |

| accepting | anxious or nervous | angry | capable | compassionate |

| confident | determined | dreadful | empowered | enthusiastic |

| excited | fearful | fortunate | guilty | happy |

| hopeful | hurt | inspired | lonely | loved |

| numb | peaceful; | resentful | resigned | sad |

| scared | tired | uncertain | | |

|Other:       |

|Nutrition |

|Food/Drink |Frequency |Comments |

| |Monthly |Weekly |Daily |Multiple Times a | |

| | | | |Day | |

|Soda/Soft drinks | | | | |What type(s)?       |

|Alcohol | | | | |What type(s)?       |

|Herbal tea | | | | |What type(s)?       |

|Red meat | | | | | Beef Lamb |

|White meat | | | | | Poultry Pork |

|Eggs | | | | | |

|Fish/Shellfish | | | | | |

|Nuts and seeds | | | | | |

|Fruits | | | | | Canned Fresh Frozen |

|Vegetables | | | | | Canned Fresh Frozen |

|Lentils and beans | | | | | Canned Fresh Frozen |

|Fats and oils (i.e., olive oil, | | | | |What type(s)?       |

|coconut oil, butter) | | | | | |

|Dairy products | | | | | Milk Yogurt Cheese |

| | | | | |Butter |

|Soy products | | | | |What type(s)?       |

|Whole grains | | | | |What type(s)?       |

|Grain-based products | | | | | Bread Pasta Crackers |

| | | | | |Cereal |

|“Junk” and fast food | | | | |What type(s)?       |

|Fried foods | | | | |What type(s)?       |

How many times a week do you eat each meal at home (vs. out)?

      Breakfast       Lunch       Dinner

Approximately how many ounces of water do you drink per day?

      ounces Bottled Filtered Tap

Where do you grocery shop?

     

|3-Day Food Diary |

|Record information as soon as possible after the food has been consumed. Please include all beverages, even water. |

|Day 1 |Day 2 |Day 3 |

|Breakfast |Breakfast |Breakfast |

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|Snack |Snack |Snack |

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|Lunch |Lunch |Lunch |

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|Snack |Snack |Snack |

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|Dinner |Dinner |Dinner |

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|Snack |Snack |Snack |

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|Significant Life Events |

|Please list major events in the last 10 years of your life and their corresponding dates. Include births, deaths, marriage, divorce, accidents, moves, job changes,|

|illness, miscarriages, and anything else you feel greatly impacted your life. |

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|Date |Event |

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Thank you for taking the time to complete this questionnaire.

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