Follow-up Evaluation

Date of Last Nutritional Program

First Name

Last Name

Gender

Date of Birth

Age

Address

City

State

Zip / Post Code

Email

Daytime Phone

Evening Phone

Height

Weight

Occupation

Number of hours worked per week

Relationship Status

Children

Allergies or sensitivities

Ancestory

What Blood Type (Digestive Chemistry) are you?

Since your last visit, please rank your current health concerns and rate their severity (on a scale of 1 to 10, 10 being the most severe).

Since your last visit, please tell us any additional information or concerns about your health including any new problems or injuries. Please include whats better, too!

Since your last visit, please list any medications you are currently taking (including birth control pills, aspirin, pain medications, etc).

Since your last visit, please rate you current stress level (on a scale of 1 to 10, 10 being the highest stress).

What is the main reason(s) for your stress?

If over level 5, what step(s) are you taking to reduce your stress level?

Since your last visit, have you had any dental work?

Yes
No

If yes, what was done?

Name of dentist:

Since your last visit, have you had any new physical stress? (check all that apply)

Breast implants
Other surgical implants
Tattoos
Electric surgery (liposuction, face-lift, removed moles, near-nearsightedness laser surgery)
Metal or plastic placed inside your body (ear or body piercing, pins, clamps)

Other physical stress:

Since your last visit, how is your sleep?

Since your last visit, how is your digestion?

Since your last visit, how are your daily urinations?

Since your last visit, how are your bowel eliminations?

Since your last visit, are you pregnant?

Yes
No

Since your last visit, are you breast feeding?

Yes
No

How are your monthly periods?

Since your last visit, are you going through menopause?

Yes
No

Since your last visit, have your periods stopped?

Yes
No

Since your last visit, have you had a hysterectomy?

Yes
No

Since your last visit, what kind of exercise do you do?

How often?

Since your last visit, how much natural sunlight do you receive daily outside?

Please rate how well you are able to take your recommended nutritional supplements (on a scale of 1 to 10, 10 be perfect).

Did you have any difficulties?

Yes
No

If so, what?

Please rate how well you were able to follow the recommended dietary and lifestyle suggestions (on a scale of 1 to 10, 10 being perfect).

Did you have any difficulties?

Yes
No

If so, what?

Pre-made foods:

Canned food
Boxed cereal
Frozen dinners
Bottled or frozen juices
Take-out food

Red meat (beef, pork, lamb):

Commercially grown
Naturally raised

Chicken:

Commercially grown
Naturally raised

Turkey:

Commercially grown
Naturally raised

Fish:

Canned tuna
Fresh fish
Frozen fish
At restaurants

Fresh vegetables:

Commercially grown (store-bought)
Organically grown (store-bought)
Organically grown (direct from farmer)

Fresh fruits:

Commercially grown (store-bought)
Organically grown (store-bought)
Organically grown (direct from farmer)

Whole grains:

Commercially grown (store-bought)
Organically grown (store-bought)
Organically grown (direct from farmer)

Whole beans:

Commercially grown (store-bought)
Organically grown (store-bought)
Organically grown (direct from farmer)

Eggs/Butter:

Commercial eggs (store-bought)
Naturally grown eggs
Commercial butter
Natural butter

Milk:

Commercial milk
Organic pasteurized milk
Organic goats milk
Good quality, raw whole milk

Cheese:

Commercial cheese
Organic cheese (store-bought)
Aged cheeses

Condiments:

Commercial salt and/or pepper
Pink salt (PRL)
Artificial sweeteners (Equal, Sweet 'N Low, Coffee mate, etc)
Commercial ketchup and/or mustard
Commercial vinegar
Commercial olive oil
PRL olive oil
Other PRL oils

Since your last visit, how often do you eat out at restaurants?

What type of food do you eat at restaurants?

Since your last visit, how often do you prepare meals at home?

What type of food do you prepare?

Do you:

skip meals often
have irregular eating times
eat past 7pm

Since your last visit, do you avoid food/drink that list "natural flavors" (which means hidden MSG) on the label?

Yes
No

Since your last visit, do you drink tap water or purified water?

Breakfast (identify typical time eaten):

Lunch (identify typical time eaten):

Dinner (identify typical time eaten):

Snacks (identify typical time eaten):

Please share any additional information:

Please complete the following questions carefully. This information will help us to build a specialized nutritional program, personally designed for you.

All information listed will remain confidential between client and health coach.

Personal Information

Health Challenge(s)

Other Information

Medications

Stress Level

Dental Work

New Stress

Health Overview

Sleep

Digestion

Urination

Bowels

Women Only

Exercise

Sunlight

Nutritional Progress

Food Choices

Food Habits

Eating Out

Home Meals

Meal Habits

MSG

Water

Typical Diet

Additional Information

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