LIFESTYLE / NUTRITIONAL HISTORY

Name
Email
LIFE / LIFESTYLE HISTORY
Marital Status
Occupation

Do you drink alcoholic beverages?
How much / How often do you drink?

Do you / Did you smoke?
How much / How often do you smoke?

Do you use recreational drugs?
How much / How often?
Stress Level High Medium Low
Describe any stress-reduction techniques that you utilize?
Have you ever or do you presently see a Psychiatrist / Psychologist?
Read each of the statements below and circle the corresponding number in the appropriate column that best describes your answer.
1. I get discouraged easily.
2. I don"t work any harder than I have to.
3. I seldom if ever let myself down.
4. I"m just not the goal-setting type.
5. I"m good at keeping promises, especially ones I make to myself.
6. I don"t impose much structure on my activities.
7. I have a very hard-driving, aggressive personality.
NUTRITION
Cups of coffee per day

Caf De-caf
Cups of tea per day

Caf De-caf
Cups of soda/iced tea/juice per day

Caf De-caf
Vitamin, Mineral and Supplement Intake
Dining out per week None 1 to 3 4 or more
List most frequented restaurants
Height
Highest weight or bodyfat percentage
Lowest weight or bodyfat percentage
Desired weight or bodyfat percentage
Desired shape / body type
Are there any issues regarding your nutrition history that you feel we should know?