Assessment Form (Confidential) We take a whole-person approach to your health concerns. We recognize that many health concerns have both a physical and emotional component to them. To get to the root of your concern(s), we will be asking you many questions that will help us to fully assess your concerns and the impact that it is having on your life. If any of these questions don’t apply to you or your concerns, just leave them blank. Thank you for taking the time to share your story with us! Personal DetailsName First Last Email PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of BirthHeight & WeightGenderFamily Doctor & Phone NumberDate of Initial AssessmentHealth GoalsWhat are your main health goals? Why do you wish to meet with a nutritionist? List your health goals, and describe each one.Let's Talk about Your Food & Food Habits Frequency & Times of EatingPlease share how many times a day you eat, and approximate times you eat.Eating EnvironmentDo you eat meals with family, home alone, on the run, in restaurants, etc? Do you eat sitting at a table, in front of TV or computer, standing, etc? Examples of your typical meals (breakfast, lunch, dinner, snacks)Please share 2-3 examples of your typical breakfast, lunch, dinner and snacks.Please list all the beverages you consume and how much of each you typically consume per dayHow many times per week do you eat meat/chicken?How many times per week do you eat dairy?How many times per week do you eat fish?Are there foods you avoid? Are there foods that you strongly dislike? Are there foods you have sensitivities to? Please list foods and explain.What are your favourite foods. Please list.Do you enjoy cooking? Who does the cooking? Who does the grocery shopping in your home?How many times per week to you eat out or take out food? From which restaurants? What do you typically order?Do you you consider yourself an emotional eater? Do you ever find that your eating is out of control? Please explain.If weight loss is a goal for you, how much weight do you wish to lose? When do you wish to reach your goal weight? What is your main motivation to change your weight?About Your Digestion Do you experience any symptoms after meals?Gas? Bloating? Fatigue? Other? Please explain.How frequently do you have a bowel movement?Do you strain when you have a bowel movement? Do you experience constipation? Do you have loose bowel movements? Please explain.About Your Lifestyle Do you smoke? Does anyone in your household smoke? Do you use recreational drugs?What is your current level of stress?Please indicate – 1 = low, 10 = high. How does your stress manifest? Do you use any coping mechanisms?Do you exercise?How often? For how long? What type of exercise?How would you describe your energy levels on a scale of 1(low) to 10 (high)? Do you experience any lulls through the day?How many hours on average do you sleep daily?Do you nap? Do you fall asleep easily? Do you stay asleep through the night? Do you awaken feeling rested in the morning? What is your occupation?Do you enjoy your work? How many hours per day do you work?Your Health History Please list any surgeries or illnesses and when they occurred.Have you had surgery to remove your gallbladder?YesNoFemale HealthDo you take birth control pills? Are you pregnant? Do you suffer from PMS? Are you menopausal? Have you experienced a decline in sexual interest? If yes to any of these questions, please describe:Have you had fungal infections (e.g. jock itch, athlete’s foot, yeast infections)? If yes, please describe:List all medications you are currently taking and the reasons for each. Have you taken antibiotics over the past five years? YesNoList any vitamins, minerals, herbal or homeopathic remedies you are currently taking: Is there anything else you'd like us to know about you? Please use this space to share any additional pertinent information.I understand that Carolyn Rostenne is a Registered Holistic Nutritionist. She is not a licensed medical doctor. As such, I acknowledge that it is my right and responsibility, at any time throughout my counselling with Carolyn Rostenne, to seek medical counsel and diagnosis, if so desired from a licensed medical doctor, for any present and/or future condition(s). I also reserve the right to terminate nutritional counselling at any time if so inclined.Please sign your name and include today's date.
