Health Questionnaire - Jacqui Justice

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Gender

Female

Male

Goals

Reason for Consultation

Date of Birth

Height

Weight

How many times do you usually eat per day?

Describe 3 full typical day's meals, snacks and drinks, and time of each (please be specific and very complete).

Do you...

Smoke

Drink alcohol

If so, how much and when?

Do you drink caffeine

Yes

No

What kind? How much/when?

Do you ever overeat

Yes

No

If so, which foods and how often?

Do you have any food allergies, restrictions, or sensitivities?

Describe your daily energy levels?

Do you get noticeably irritable, lightheaded, or weak if you haven't eaten in awhile?

Do you eat fast?

Yes

No

Is your eating environment peaceful or stressful?

Peaceful

Stressful

How much time do you have for meals?

How often do you have a bowel movement?

How often do you urinate?

Do you exercise? If so, what kind? How often? Since when?

My daily stress level is...

How many hours of sleep do you get on average each night?

Any problems sleeping?

Do you take nutritional supplements or vitamins? If so, which ones? (Please be specific)

Please list any prescription or over the counter medications you take on a regular basis.

Family History: Please list any disease, illness or ailments in your immediate family ( i.e. parents, grandparents, siblings)

Rank your skin without lotion.

Nutrition Questionnaire