Whole-Health Nutrition and Breastfeeding Clinic
Health History Form
**Please take a few minutes to fill out this form. Your answers will help me to know more about the kind of plan we should develop for you. Thank you!**
Personal Medical History
Please list any medical diagnoses or procedures you have had:
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If you have recent laboratory test results, please list:
Date ____________________
Total Cholesterol ________
Triglycerides ________
LDL ________
HDL ________
Glucose ________
Blood Pressure ________
Other ____________________________________________________________________
Current medications and dosage:
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Have you ever been advised by your physician to follow a special diet?
(low salt, low cholesterol, no sugar, etc) yes no
If yes, what changes did you make at that time?
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Have you ever worked with a dietitan/nutritionist? yes no
If yes, what was your experience? __________________________________________________________________
Please rate your health: excellent good fair poor
Do you take any vitamin, mineral, or food supplements? yes no
If yes, what type and dose?
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Do you have any food allergies? yes no
If yes, please specify: ________________________________________________________________________________________________________________________________________
Do you smoke? yes no
Do you drink alcohol? yes no
If yes, how many drinks per week? ________________________
Family Medical History
Have any immediate family members (parents, siblings, etc) been treated for any of the
following:
Diabetes yes no
Hypertension yes no
High cholesterol yes no
Heart disease yes no
Stroke yes no
Cancer yes no
Other (list) ________________________________________________________________________________________________________________________________________
Eating Patterns
How many meals a day do you eat? ________________________________________________________________
Do you skip meals? _________ If yes, which ones do you skip and why?
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How often do you snack? Once daily Twice daily Three times daily
When do you usually snack? ____________________________________________________________________
What foods do you snack on most frequently?
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How many meals per week do you eat at a restaurant? __________________________________________
Which restaurants do you normally choose?
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How many meals per week do you eat at fast‐food restaurants? ________________________________
How does your meal and snack pattern vary on the weekend vs. during the week?
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What are your favorite foods? ____________________________________________________________________
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List any foods you avoid eating: ____________________________________________________________________
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Have you ever used laxatives for weight control? yes no
Have you ever vomited for weight control? yes no
Exercise and Activity
Do you exercise? yes no
If yes, please describe: ____________________________________________________________________
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Do you like to exercise? yes no
What physical activity do you dislike? _____________________________________________________________
Wrap-up
Is there any other information you would like me to know about?
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Thanks so much for taking the time to fill this questionnaire out. Please email it to me as an attachment to wendy@whole-healthnutrition.com or you can send it to my home at 118 N Jefferson St, Verona, WI 53593.
I look forward to our up coming meeting!!
Wendy