Step 1 of 7 14% Name(Required)If you are a caretaker, please list your name as “caretaker” and their name as “client”. First Name Only NameClient Name, if different from above First Last Contact Email(Required) Date of Birth(Required) MM slash DD slash YYYY Residing State(Required)Age(Required)Please list your top 3 health and wellness concerns.(Required)Please indicate your personal motivations behind the desire to change lifestyle and diet.(Required)Check all that apply. Improved self confidence Weight loss Increased energy Improved athletic performance To improve health test outcomes for blood glucose, cholesterol, etc. To prevent future disease To better manage my chronic disease or condition To reduce current medications under my doctor’s supervision To care for my family in a better capacity and to be an example of healthy living to my family I am a caretaker of an individual with a chronic condition and I am seeking assistance on their behalf, to provide better care. Please indicate what obstacles you have faced or might face when trying to improve your health.(Required)Check all that apply. Emotional stress Work schedule/requirement Lack of support from relatives, family members in your home, or friends Lack of time to prepare healthy meals Lack of money to buy nutritious foods Hectic travel schedule Focus and attention issues Addictive behaviors related to food Do you smoke? (Yes/No) If so, how many days per week?(Required)Have you recently or do you currently drink alcohol? (Yes/No) If so, how often (in number of drinks) do you or did you drink per day, per week?(Required)If you have stopped drinking alcohol, how long in number of approximate days have you been alcohol free?(Required)Have you recently or do you currently ingest recreational drugs? (Yes/No) If so, what type?(Required)What is your intake per day or per week, if applicable? What is your coffee, soda, and chocolate intake per day or per week?Caffeinated Coffee(Required)Caffeinated Tea(Required)Caffeinated Energy Drinks(Required)Caffeinated Soda(Required)Chocolate(Required)Current Nutrition InformationHow many times per day do you eat?(Required)How many snacks do you ingest per day?(Required)Without thinking, what is your "go-to" snack?(Required)What is your daily or weekly raw fruit serving intake?(Required)Example: 3 fruit servings per day.What is your daily or weekly cooked or raw vegetable serving intake?(Required)Example: 8 vegetable servings per week. In your opinion, do you overeat?(Required)If so, how often?If you overeat, when does it occur most?Breakfast, Lunch, Dinner, or when you snack?Do you eat in front of a screen (TV, computer, cell phone)?What types of food do you crave?(Required)Check all that apply. Sweets/desserts Chocolate Bread/pasta Fried foods/salty foods Dairy Meats Alcoholic beverages How often, in days per week, do you eat at home?(Required)How often, in days per week, do you eat at a restaurant?(Required)How often, in days per week, do you grab fast food?(Required) Before you started eating better (if applicable), what did your daily food intake consist of?List foods that you eat for breakfast, lunch, dinner, and snacks.Breakfast(Required)Lunch(Required)Dinner(Required)Snacks(Required)Current Health InformationCurrent Weight(Required)Current Height(Required)Do you suffer from any chronic conditions such as sinus infections, UTI's, etc.?(Required)How often do you have bowel movements per day or per week?(Required)What is the consistency of your bowel movements?(Required)(Soft, hard, mushy, etc.)Are bowel movements painful?(Required) What medical conditions have you been diagnosed with?(Required)Also include what year you were diagnosed with this condition.What medical conditions have you been diagnosed with?(Required)Also include what year you were diagnosed with this condition.What, if any, surgeries have you had? Why and when?(Required)What prescribed medications are you currently taking and what is the dosage prescribed?(Required)What herbs and supplements are you currently taking and what are your dosages?(Required)Are you currently under the care and supervision of a licensed medical doctor?(Required)When was your last physical exam?(Required)What physical symptoms are you experiencing that you are concerned with at this time?(Required)What mental health symptoms are you experiencing that you are concerned with at this time?(Required) How many hours of sleep are uninterrupted?(Required)How many hours of sleep do you get each night?(Required)How often do you urinate in a 24-hour period, on average?(Required)Also note if it is ever painful for you to urinate.What is the condition of your hair, skin, and nails?(Required)Normal, oily, or dry skin? Brittle, thin, or thick nails?What is the condition of your hair, skin, and nails?(Required)Normal, oily, or dry skin? Brittle, thin, or thick nails?Do you have allergies to foods, chemicals, or indoor/outdoor substances?(Required)If so, please list each allergy and indicate if the allergy has been tested. Also list symptoms you experience from each allergy.What is your energy level?(Required)High, Normal, or LowDo you have any strange habits related to food? If so, what are they?(Required)Do you suffer from undiagnosed depression, anxiety, or stress-related conditions? If so, what are they?(Required)How often do you engage in exercise?(Required)What types of exercise do you engage in?(Required)If weight is a concern, what is your ideal weight?This information is used for the purpose of providing you with personal evidence-based nutrition and wellness information to better assist you in managing your own health under the supervision of your healthcare provider. It is not used to diagnose or treat any medical conditions. Stephanie Wilkins is a health educator and does not diagnose or advise clients to change or add medications or supplements of any kind. See your healthcare provider before adding or making any changes to medications or supplements.EmailThis field is for validation purposes and should be left unchanged. Δ
