Your Name

Date

Address

Street Address

Address Line 2

City

State

Zip Code

Info

Phone Number

Your Email

Birthdate

Gender

Height

Weight

Body Frame SmallMediumLarge

Marital Status

Children and Ages

Family Living Situation

Occupation

Exercise/Recreation and Number of Times Per Week

Health Concerns

Describe any health concerns

How have you dealt with these concerns in the past (doctors, self-care)?

What other health practitioners are you currently seeing (name, specialty, phone #)?

List any medicine or supplements you are currently taking.

Have any other family members had similar problems (describe)?

Health Hazards

Describe any noticeable correlation between your problems and stress (work, family, relationships, financial).

List any toxicity—exposures and sensitivities to chemicals (tap water, air pollution, job and home exposures, cosmetics, food and chemical residues, e.g., Nutrasweet, and medicines including aspirin, birth control, etc.).

List any trauma (unresolved, physical and/or emotional wounds or abuse). What re-stimulates it? How does it affect your diet and health habits?

Describe any mal-nutrition (periods of eating junk food, binge eating, dieting).

List any addictive behaviors (past or present use and abuse of alcohol, drugs, tobacco, caffeine, co-dependency, workaholic, etc.).

Dietary Habits and Choices

What were your diet and family eating habits like growing up?

Describe your diet at the onset of your health problems.

How has your diet changed in relationship to your health problems? (Special diets?)

Describe the foods you eat (comfort foods) when you are, Hungry: Angry: Lonely: Tired: Depressed: Celebrating:

How is your mood and energy level affected by eating these foods (nourishing or numbing)?

Lifestyle, Mood and Energy

How is your sleep? Can you get to sleep easily? Can you stay asleep?

For Women: How are/were your cycles? Do/did you have PMS? Painful periods?

How are your moods in general? Do you experience more anxiety that you wish? Depression? Anger?

On a scale of 1 to 10, 1 being the worst and 10 being the best, describe your usual level of energy.

What are your health goals?

SECTION 1 (Commercial Food): How many servings per week do you eat/drink? Check one:

COFFEE, 1 cup, 8 oz serving
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

SODA (sweetened), 1 can, 12 oz
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

SODA (sugar free), 1 can, 12 oz serving
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

ALCOHOL, Beer 12 oz, Wine 3 oz, Spirits 1 oz serving
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

SPORT OR ENERGY DRINKS, 1 cup, 8 oz
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

SUGAR SUBSTITUTES (Splenda, Sweet-nLow, Equal, diet) 1 packet or 1 tsp
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

CHIPS, CRACKERS 1 oz, small handful
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

COOKIES, PASTRIES, 3 oz, palm-sized cookie or medium-sized pastry
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

COMMERCIAL EGGS, EGG PRODUCTS, 1 egg or equivalent in ‘egg beater’ serving
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

BREAD, BAGELS, PASTA (not whole grain), 1 slice, half bagel, or 1 cup serving
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

COMMERCIAL DAIRY PRODUCTS (cow), 1 cup milk/yogurt, 1 oz cheese, 1 tsp butter serving
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

COMMERCIAL MEAT, FARMED OR CANNED FISH, FAST FOOD, 3 oz, palm sized serving
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

SECTION 2 (Natural Food): How many servings per week do you eat/drink? Check one:

WATER, 1 glass, 8 oz cup
0-2/day = 7-14 cups/week3-4/day =21-28 cups/week5-6/day = 35-42 cups/week7-8/day = 49-56 cups/weekMore than 8/day = >56 cups/week

TEA, 1 cup, 8 oz serving, black, green, or herbal
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

FRESH FRUIT, 1 medium-sized piece or half cup
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

LEAFY VEGETABLES, 1 cup serving, (lettuce, spinach, kale, collard greens, etc)
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

STARCHY & CRUNCHY VEGETABLES, 1/2 cup serving, (root vegetables, celery, carrots, etc.)
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

NUTS, SEEDS, NUT/SEED BUTTERS, 1 oz, small handful serving, (almonds, sunflower, tahini, etc.)
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

BEANS, LEGUMES, 6 oz cooked serving, (lentils, black beans, tofu, tempeh, etc.)
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

WHOLE GRAINS, 1/2 cup cooked serving, (brown rice, quinoa, oatmeal, etc.)
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

HERBS, SPICES, 1/2 tsp serving (basil, thyme, garlic, ginger, etc.)
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

ORGANIC EGGS, free range, 1 egg serving
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

ORGANIC DAIRY, (sheep, goat, cow), 1 cup milk, 1 oz cheese, 1 tsp butter serving
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

ORGANIC MEAT, WILD FISH, 3 oz serving
0-2/wk3-4/wk5-7/wk8-14/wkMore than 14/wk

SECTION 3

Check all that apply
Overeat when excited, stressed, or sadTake less than 10 min for each mealEat restaurant or take-out foodEat while driving, working, or at computerWork more than 10 hours per dayWatch TV/computer for entertainment 2 hrs/daySmokeSleep less than 7 hours per night

SECTION 4

Check all that apply
Eat slowly and chew food thoroughlyDo cardio exercise 30 min (walk, run, bike, dance, etc.)Stretch and/or do yogaDo strength training (weights, Pilates)Spend quality time with family & friendsRelax and/or meditateHave adequate emotional supportEnjoy a hobby, arts, music, reading, or free time

SECTION 5

Check all that apply
Fatigue or low energyMood disturbanceWeight issuesPain and/or inflammationSleep issuesDigestion issuesLack of mental clarityLow productivityFemale or male issuesFamily or relationship issues

SECTION 6

Check all that apply
Are you committed to healthy diet and lifestyle changes?Are you interested in classes?Are you interested in one on-one- counseling for 1 or more months?

Steven provides health and wellness services to individuals and groups on health supporting foods and lifestyle practices to teach individuals to make good decisions to support their well being. Steven is not a Registered Dietitian or a Medical Doctor. As such, he does not provide medical nutrition services, or diagnose and treat disease. Rather, he educates people on the benefits of a healthy lifestyle to improve their quality of life. Steven advises people with existing medical problems to consult with medical doctors. Steven shares evidence-based health information, whether to class participants or wellness counseling client sessions. I agree to participate with Steven Ashton (NutritionAsRx) for nutrition education during one on one counseling sessions. My commitment is to attend as many counseling sessions as agreed upon with Steven. I understand that information provided on the relationship between nutrition and health is NOT meant to replace professional medical treatment for any health problem or condition. Health education and medical care are complementary and integrative when properly delivered. I choose to improve my health by assuming greater self-responsibility to reduce or eliminate unhealthy behaviors that are contrary to my well-being. By submitting this form, I agree to be a participant and to satisfy all above requirements.

Your Initials

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