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Jacqui's Virtual Dispensary
Health Questionnaire for Women
admin
2022-10-18T02:15:38+00:00
Women's Nutrition Questionnaire
Step
1
of
11
9%
Name
(Required)
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
(Required)
Email
(Required)
Goals
Reason for Consultation
Date of Birth
MM slash DD slash YYYY
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 crave any of the following? (Please check all that apply)
Sugar
Fried Foods
Milk
Fat
Chocolate
Meat
Pasta
Alcohol
Desserts
Fish
Bread
Other
Select All
Which oils do you use or consume? (Please check all that apply))
Butter
Coconut Oil
Corn Oil
Soybean Oil
Margarine
Hemp Oil
Crisco
Canola Oil
Mayonnaise
Grape Seed Oil
Olive Oil
Peanut Oil
Vegetable Oil
Sun/Safflower Oil
Other
Do you have problems chewing or swallowing?
Yes
No
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 energy level is...
Poor
Fair
Good
Excellent
My energy level after exercise
Poor
Fair
Good
Excellent
My general enjoyment of life is...
Poor
Fair
Good
Excellent
My dental health is...
Poor
Fair
Good
Excellent
My digestion is...
Poor
Fair
Good
Excellent
My daily stress level is...
None
Low
Moderate
High
Very high
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.
Very Dry
Dry
Normal
Oily
Combination
Please check any of the following that pertain to you (past or present):
Acne
Addiction (Alcohol, drugs)
Anemia
Arthritis (Rheumatoid or Osteo)
Anorexia
Anxiety
Bladder Infections
Bloating (gas or indigestion)
Blood Sugar Problems
Bronchitis
Cancer
Colds (frequent)
Cold Sores
Chronic Fatigue
Constipation
Dandruff
Diarrhea
Difficulty losing weight
Difficulty gaining weight
Diabetes 1
Diabetes 2
Diarrhea
Emotional problems
Emphysema
Fainting
Gall bladder problems
Gout
Hair Loss
Headaches
Heart disease
Heartburn
Hemorrhoids
Herpes Simplex
High blood pressure
High cholesterol
HIV
Hot Flashes
Hypoglycemia
Insomnia
Intestinal problems
Kidney stones
Liver problems
Loose stools
Memory loss or confusion
Panic Attacks
Parasites
Pregnant/nursing
Respiratory problems
Ringing in ears
Seizures
Severe mood swings
Skin conditions
Stroke
Thyroid conditions
Yeast infections
Please check all that apply:
PMS
Irregular periods
Loss of periods
Birth control pills
Menopause
Painful intercourse
Children
Hysterectomy
Feel free to expand on any concerns that you think are important/relevant to your health.
Email
This field is for validation purposes and should be left unchanged.
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