Vitality Wellness Assessment

One's health and well-being are influenced by many different things, including lifestyle, family history, emotional health, and nutrition/eating habits. Please complete the following questionnaire to the best of your ability to give us an overall view of your general lifestyle and health habits. New Client Nutrition Assessment Form.

First Name*
Middle Name*
Last Name*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please indicate your preferred method of contact:
- home
- work
- cell
- email
Cell Phone
Birth Date*
MM slash DD slash YYYY
Age
Work Phone*
Email*
Home Phone*
Height*
Weight*
Sex*
Blood Type
- A
- AB
- B
- 0
- unknown
Occupation*
Marital Status*
Do you have children?*
- Yes
- No
Age of children*
Are you pregnant?*
- Yes
- No
Due Date*
MM slash DD slash YYYY
With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.) Example: Sarah, age 7, sister*
Primary Care Provider*
Date of last physical exam*
MM slash DD slash YYYY
Other doctors or practitioners you see*
Would you like to receive e-mail notifications regarding cooking classes/demonstrations?
If yes, please sign*
GOALS AND READINESS ASSESSMENT
I would like to visit with the dietitian, today because...
My food and nutrition-related goals are...
My overall, health goals are...
if I could change three things about my health and nutritional habits, they would be....
1
2
3
The biggest challenge(s) to reaching my nutrition goals is/are:
In the past, I have tried the following techniques, diets, behaviors, etc. to reach my nutrition goals...
On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following:
To improve your health, how ready/willing are you to...
1
2
3
4
5
- Significantly modify your diet
- Take nutritional supplements each day
- Keep a record of everything you eat each day
- Modify your lifestyle (ex: work demands, sleep habits, physical activity)
- Practice relaxation techniques
- Engage in regular exercise/physical activity
- Have periodic lab tests to assess your progress
PAST MEDICAL AND SURGICAL HISTORY
Please indicate whether you or your relatives have been diagnosed with any of the following diseases or symptoms Specify which relative and the date of diagnosis). Relatives include parents, grandparents, siblings. Illness/Disease/Symptom
Self:
Relative:
Describe/Specify
- Allergies (please specify type of allergy!
- Fibromyalgia
- Anemia
- Food Allergles or Sensitivities
- Anxiety or Panic Attacks
- Fungal infection (athlete's food, ringworm, other)
- Arthritis (osteoarthritis or rheumatoid)
- Gallbladder Disease/Gallstones (specify)
- Asthma
- Gout
- Autoimmune condition (specify type)
- Heart attack/Angina
- Bronchitis
- Heartburn
- Cancer
- Heart disease (specify)
- Chronic Fatigue Syndrome
- Hepatitis
- Crohn's Disease or Ulcerative Colitis
- High blood fats (cholesterol, triglycerides)
- Depression
- High blood pressure (hypertension)
- Diabetes (Specify: Type I, II, Pre-diabetes, Gestational Diabetes)
- Hypoglycemia (low blood sugar)
- Dry, itchy skin, rashes, dermatitis
- Intestinal Disease (specify)
- Eczema
- Inflammatory Bowel Disease (Crohn's or Ulcerative Colitis)
- Emphysema
- Irritable bowel syndrome
- Epilepsy, convulsions, or seizures
- Kidney disease/failure or Kidney stones
- Eye Disease (please specify)
- Lung disease (specify)
- Liver disease
- Mononucleosis
- Osteoporosis
- PMS
- Polycystic Ovarian Syndrome
illness/Disease/Symptom
Self:
Relative:
Describe/Specify
- Pneumonia
- Prostate Problems
- Psychiatric Conditions
- Seizures or epilepsy
- Sinusitis
- Sleep apnea
- Stroke
- Thyroid disease (hypo- or hyperthyroid)
- Urinary Tract Infection
- Other (describe)
Injuries
Age
Describe/Specify:
- Back injury
- Broken (specify)
- Head injury
- Neck injury
- Other (describe)
Diagnostic Studies
Age at study
Describe/Specify:
- Barium Enema
- Bone Scan
- CAT Scan: Abdomen., Brain, Spine (specify)
- Chest X-ray
- Colonoscopy or Sigmoidoscopy (specify)
- EKG
- Liver scan
- NMR/MRI
- Upper GI Series
- Other (describe)
Operations
Age at operation
Describe/Specify
- Dental Surgery
- Hysterectomy
- Gall Bladder
- Tonsillectomy
- Other (describe)
Please complete the following information concerning your family's health history: If Living or if Deceased.
Age
Health
Age at Death
Cause
Age
Health
Age of Death
Cause
Father
Spouse/Partner
Mother
Children
Siblings
MEDICAL SYMPTOMS QUESTIONNAIRE

Rate each of the following symptoms based upon your typical health profile for the past 30 days. If you have been having recent or somewhat severe health symptoms, please indicate that you will fill out the questionnaire for the past 48 hours.

Past 30 days Past 48 hours

Point Scale

0- Never or almost never have the symptom 1 - Occasionally have it, the effect is not severe 2-Occasionally have it, the effect is severe

3-Frequently have it, the effect is not severe

4-Frequently have it, the effect is severe
HEAD
DIGESTIVE TRACT
EYES / EARS
JOINT/MUSCLE
NOSE
WEIGHT
MOUTH/THROAT
ENERGY/ACTIVITY
SKIN / HEART
MIND
LUNGS
EMOTIONS
OTHER
MEDICATION, SUPPLEMENT, AND ANTIBIOTIC INTAKE:

Please provide the names of medications, supplements, and/or antibiotics that you are currently taking:
Medication/Supplement/ Antibiotic:
Dose:
Units:
Frequency:
Start Date:
MM slash DD slash YYYY
Stop Date:
MM slash DD slash YYYY
Example:
One-a-Day (brand) Men's Multivitamin:
1200 / Mg. / Daily. 08/12/2007 current
Are you allergic to any medications? Yes or No Please list:
- Yes
- No
Please indicate how often you have taken antibiotics during each life stage:
Infancy/ Childhood
Teen
Adulthood
Lifestyle
Physical Activity: Using the table, please describe your physical activity.
Activity
Type/Intensity:
(low-moderate-high):
#Days:
per week:
Duration(minutes):
Stretching/Yoga: (minutes):
Cardio/Aerobics (walking, jogging, biking, etc.):
Strength training (weight lifting, pilates, some yoga):
Sports or Leisure:
Other (specify/describe):
Does anything limit you from being physically active?
Indicate daily stressors and rate the level of stress from 1 (extremely low) to 10 (extremely high):
Work
Family
Social
Financial
Health
Other
What helps you to unwind?
On average, how many hours of sleep do you get? Weekdays
On average, how many hours of sleep do you get? Weekend
Do you smoke?
- Yes
- Never
- Sometime
Alcohol
- Yes
- Never
- Sometime
Pastor Currently?
How long
Pastor Currently?
Type/amount/frequency
Drug Use:
Never
Prefer not to discuss Type/frequency
WEIGHT HISTORY: Past
WEIGHT HISTORY: Currently
Would you like to be weighed today?
- Yes
- No
Height
Current Weight
Desired Body Weight
Highest Adult Weight
When?
Weight 1 year ago
Do you associate any digestive symptoms with eating certain foods? Yes or No.
How often do you have a bowel movement?
If you take laxatives, what type/brand and how often:
Would you describe your stools are hard, soft, or loose? (circle one)
- Hard
- Soft
- Loose
Please indicate how often you experience the following symptoms:
Heartburn:
Often:
Sometimes Rarely:
Gas:
Often:
Sometimes:
Rarely:
Bloating:
Often:
Sometimes:
Rarely:
Stomach Pain:
Often:
Sometimes:
Rarely:
Nausea/Vomiting:
Often:
Sometimes:
Rarely:
Diarrhea:
Often:
Sometimes:
Rarely:
Constipation:
Often:
Sometimes:
Rarely:
DIET HISTORY
Do you follow any special diet or have diet restrictions or limitations for any reason (health, cultural, religious or other)?
Please list any food allergies, sensitivities or intolerances
Who prepares the majority of your meals?
Who shops for food?
Where do you shop for food?
What percent of the foods you eat are... whole
%organic
% convenience %
If you do, how much time do you spend cooking/preparing meals each day?
Please indicate the materials you use for cooking and food storage:
Iron
Iron
Do you find cooking difficult? describe
INTAKE INFORMATION:
IIf you follow a special diet/nutritional program, check the following that apply:
Weight Loss:
Which meais do you eat regularly, check all that apply:
Breakfast
Lunch
Dinner
The nutrition/eating habits that are most challenging for me:
The nutrition/eating habits that I am most pleased with:
Beverage Intake: Please indicate the beverages you drink, and how often you drink them. Fill in the "Daily Amount", "Weekly Amount", and/or "Monthly Amount"
Beverage Type:
Daily Amount:
Weekly Amount:
Monthly Amount:
Example::
Coffee:X regular, decaffeinated latte:
2-8 oz cups:
Water:
Tea: what type(s)?:
Milk alternative Type:
Other:
Food Intake: Please indicate the frequency that you eat the following:
How often do you eat:
- Never ( 2-3 times/mo.
- 1 time/week
- 2-3 times/week
- 1 times/day
- 2-3 time/day
Fast food:
Restaurant food:
Vending machine food:
Cafeteria or buffet food:
Frozen meals:
Home-cooked meals:
Leftovers:
Beef (hamburger, steak, etc.)
Pork (chop, loin, ham, bacon, etc.)
Liver Lamb:
Poultry (chicken, turkey, etc.).
Deli meat, type:
Fish, type:
Soy-foods, type:
Beans, type:
Crackers, type:
Cookies, cakes, muffins:
Whole grains, type:
Fresh/Raw vegetables:
Cooked vegetables:
Fruit, fresh or frozen:
Canned Vegetables or Fruit:
Margarine:
Dairy (Milk, yogurt, cheese, butter):
French fries:
Fried meat (chicken, fish):
Foods with added:
sweeteners/sugar, type:
Meal Replacements, type:
Food cravings
Food dislikes
Eating Style:
Based on how you eat on a regular basis, please check all that apply:
Travel Frequently
Regular Meal Consumption
The food/nutrition questions that I would like to ask are:
CLIENT PERSONAL TRAINING AGREEMENT
the Client, have been informed, understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment are potentially hazardous activities. I also have been informed, understand and am aware that fitness activities involve a risk of injury and that I am voluntarily participating in these activities and using equipment with full knowledge, understanding and appreciations of the dangers involved. I understand that precautions will be used during this evaluation/training program to prevent physical injury to me.
However, in the event of physical injury resulting from the fitness evaluation procedures, equipment usage or training protocols, no medical treatment or monetary compensation will be provided by Whole-Listic Retreats. I assume the full risk associated with the participation in the training programs and agree to hold harmless High Performance Athletic Training Center and all employees associated with this company. I acknowledge that Whole-listic Retreats is relying solely on information provided by me regarding my medical history and physical condition, in allowing me to participate in any evaluation or training session.

I certify that I have made a complete disclosure of my medical history and physical condition, and that the information provided is true and correct. I certify that I have made a complete disclosure of my medical history and physical condition, and that the information provided is true and correct.
SESSION CANCELLATION: 1, (print)
the Client, understand that individual session cancellations are to be made at least 24 hours in advance of session request, failure to do so will result in the cancellation of that session, and that I will be charged for the session. I understand that arriving 15 minutes or more later for a session will also result in cancellation of the session and I will be charged for the session. Extensions on packages will not be given due to infrequent use or cancellation of sessions.

REFUNDS: In the event that a medical problem or prolonged circumstances prevents completion of the contracted sessions within the time period set forth in this agreement, the Client may take an extended period of time to complete sessions. Length of extension will be determined upon presentation of medical documentation.
Number of Sessions:
Expiration Date:
MM slash DD slash YYYY
I hereby understand and agree to the terms and conditions of this contract.
Signature of Client Date:
Signature of Trainer:

Donna has captivated many individuals over the years as a Speaker | Inner Healing Coach | Facilitator. Her healing gifts and lessons of how to live a holistic life of vitality have been positively received and implemented by many clients over the years.