Blue Tree Nutrition
Blue Tree Nutrition, LLCValerie Polley, RDN, CDNNutrition Health QuestionnaireThe following information is confidential and will not be revealed to anyone outside Blue Tree Nutrition, LLC without your written consent.Personal InformationName: ____________________________________________________________ Date: ___________________________Height: ________ Weight: ________ Weight loss or gain: ________ Age: ________ Sex: _____M _____FHave you been diagnosed with irritable bowel syndrome?_____Yes_____NoHave you been diagnosed with small intestinal bacterial overgrowth?_____Yes_____NoHave you been diagnosed with celiac disease?_____Yes_____NoHave you been diagnosed with inflammatory bowel disease?_____Yes_____NoDo you have a history of foodborne illness?_____Yes_____NoTestingPlease check any of the following for which you have been tested and note any abnormal results:_____Celiac Testing (_____biopsy/_____blood test):_____Lactose intolerance breath test:_____Fructose malabsorption breath test:_____Sucrase-Isomaltase deficiency breath test:_____Small intestinal bacterial overgrowth breath test:_____Methane tested _____ Hydrogen tested _____Unsure_____Thyroid labs:_____Vitamin D: _____Allergy testing:What type? _____IgE _____IgGGI ProceduresPlease check any procedures you have completed and any abnormal results:_____Colonoscopy:_____Endoscopy:_____Gastric emptying study:_____Upper GI X-Ray:_____Anal manometrySymptomsOn a scale of 1-4 (4=terrible, 0=non-existent) please circle a number that identifies the level of discomfort of the following symptoms:Gastrointestinal SymptomsGas01234Bloating01234Nausea01234Diarrhea01234Constipation01234Abdominal Pain01234Incomplete Emptying01234Early Satiety01234Reflux/GERD01234Systemic SymptomsBody Aches01234Joint Pain01234Sleep Disturbance01234Fatigue01234Headaches01234Anxiety01234Dry Eyes01234Atopic Dermatitis01234Itchy Skin01234Hives (Uticaria)01234Based on the above symptoms, how frequently during the week or month do your symptoms impact the quality of your life?Medical HistoryPlease list any other relevant medical history, age of onset and if there is any explanation needed.ConditionAge of OnsetExplanation if NeededRelevant Family Medical History: ________________________________________________________________MedicationsPlease list medications you are currently taking, dosage per day, and the reason for taking them.MedicationDosage per DayReason for TakingCheck below if you are taking any of the following and mark dosage:Supplement/BrandDosage per Day_____Peppermint Oil_____Iberogast or IBgard_____Vitamin D _____Calcium (List type, such as carbonate, etc.)_____Iron_____Fiber Supplements_____Laxative_____Probiotic_____MultivitaminVitamins, Minerals, Supplements not listed above.Please list any supplements, the dosage per day, and the reason for taking them.Supplement/BrandDosage per DayReason for TakingDaily eating patternBelow please list what you frequently eat as a meal or snack. If you do not eat a meal or snack listed, please leave it blank.MealFood ConsumedBreakfastSnackLunchSnackDinnerSnackDo you drink caffeinated beverages such as teas, coffee and soda? If yes, how much? ___________________________________ How often? ___________________________________Do you drink alcohol? If yes, how much? ___________________________________ How often? ___________________________________How often do you eat out? _________________________________________________________________________Which restaurants do you choose most frequently? __________________________________________Who does the grocery shopping/prepares meals?_____________________________________________If you are on a gluten free diet, is your kitchen completely gluten-free or do other family members still eat gluten? _________________________________________________________________________________________________________Eating Questions1. Do you struggle finding foods to eat? _____Yes _____NoIf yes, please explain: _______________________________________________________________________________2. Have you ever been diagnosed with an eating disorder? _____Yes _____NoIf yes, is this still an active issue for you? _____Yes _____NoAre you in treatment? _____Yes _____No3. Do you spend much of your day thinking about food, food related decisions or meal planning? _____Yes _____No4. Do you have fears or guilt associated with eating certain foods? _____Yes _____NoExercise and Physical ActivityOver the past 6-12 months, please describe your typical exercise routine.Type of ExerciseFrequency (days per week)Duration (how long per day)What are your primary goals for your nutrition consultation?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________To the best of my knowledge, the information I have provided is accurate. I will agree to inform Valerie Polley, RDN, CDN of any changes in my health status.Client Signature:___________________________________________________________________Date:_____________Signature of Parent or Legal Guardian:__________________________________________Date:_____________(If client under 18 years of age) ? 2018 Blue Tree Nutrition, LLC ................
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