Therapy Intake Form - Health Equations (Page 2 of 2) in pdf

health equation

Name

______________________________________

INTAKE FORM,

page 2

FOOD DIARY

DIGESTION INDICATO R

Please indicate the

you have of

NUMBER OF SERVINGS PER WEEK

C H E C K L I S T

each of the following foods:

❑

food allergies/intolerances: ______

beef_______________

fresh fruit ___________________

____________________________

poultry

fresh vegetables _____________

❑

white__________

crave specific foods: ___________

breads, cereals, grains and pastas:

dark___________

____________________________

~refined/processed__________

❑

avoid specific foods: ___________

lamb_______________

~whole grain ______________

____________________________

fish________________

legumes________ seeds ________

❑

low fat or no animal fat

n u t s / n u t b u t t e r s ______________

❑

pork_______________

low or no carbohydrates

❑

oils, please specify

weekly

burning sensation in stomach

soy “milk”__________

kind(s)

servings

which eating relieves

tofu/soy

❑

______________________ _____

burping

products__________

❑

______________________ _____

acid indigestion, sour stomach,

milk_______ %fat____

heartburn

______________________ _____

❑

tight/full upper abdomen after eating

yogurt _____ %fat____

protein powder, specify kind - weekly

❑

pale stools

cottage

_______________________ _____

❑

cheese____ %fat____

crave fats

sweets (cookies, cakes, sodas,

❑

gall bladder attacks or stones

eggs

______

(# per week)

c a n d y, ice cream, e t c .)__________

❑

abdominal bloating / distention

butter______________

c a ffeine: tea______ coffee_______

❑

flatulence (gas)

(sticks per week)

dark soda_____ light soda______

❑

coated tongue

cheese _____________

wine_____ beer_____ liquor_____

❑

(ounces per week)

diarrhea

❑

constipation / incomplete evacuation

How much calcium do you supplement daily? ______ mg

❑

alternating diarrhea and constipation

For how long? (circle one) weeks, months, years

❑

loss of taste for meat

How much magnesium do you supplement daily? ______ mg

❑

always hungry

For how long? (circle one) weeks, months, years

❑

low blood sugar

high blood sugar

E X E R C I S E

SLEEP CHECKLIST

Please describe the type, frequency and duration of exercise.

Number of hours ________

____________________________________________________

Sleep quality:

____________________________________________________

❑

poor

good

❑

____________________________________________________

fair

excellent

❑

awake during night at ______ a.m.

For Calculation of %BODY FAT

❑

awake rested

❑

difficulty falling asleep

H e i g h t ________

We i g h t ________

❑

awake too early

Abdomen Measurement at Navel ________ inches

❑

frequent snoring

( Women only) Hips Measurement at the Widest Point _______ inches

❑

another person has witnessed you

stop breathing during sleep

(Men only) Wrist Measurement ________ inches

PLEASE INCLUDE A LIST OF ALL SUPPLEMENTS AND MEDICATIONS YOU ARE

CURRENTLY TAKING. BE SURE TO LIST THE DOSE AND FREQUENCY FOR EACH ONE.

Therapy Intake Form - Health Equations Page 2

Related Articles

Related forms

Related Categories