Palo Alto Nutrition

Name

Age

Place of Birth

Gender*

Female

Male

Height

Current Weight

Would you like your weight to be different? If so, what?

Blood Type

Relationship Status

Single

Married

Separated

Divorced

It's complicated

Others

Children

Pets

What hobbies or activities do you enjoy?

What are your top five health concerns?

What would you like to accomplish or gain from this consultation?

Do you sleep well?

Do you wake up during the night? If so, what time(s)?

What time do you go to bed?

What time do you generally wake up?

How do you feel when you wake up?

Do you drink caffeinated beverages?

Every day

A few times a week

Once a week

Rarely

Others

What types of caffeinated beverages do you consume?

Coffee

Decaf

Black Tea

Green Tea

Chocolate

Sodas

Red Bull

Others

How many total daily ounces of caffeinated beverages do you consume?

Do you smoke?

Yes, daily

Yes, occasionally

No, I quit

Never

If yes, how much and how often?

If you quit, how and how long ago?

Have you been or are you exposed to secondhand smoke?

If so, how and how long?

Do you drink soda?

Yes, regular soda

Yes, diet soda

Others

If so, how much and how often?

Do you drink alcohol?

Yes, daily

Yes, a few times a week

Yes, rarely

Never

Others

if so, what do you drink and how much?

Have you been exposed to toxic substances at home or at work?

Do you have any allergies?

How much water do you drink per day?

What role does exercise play in your life?

Prescription & Non-Prescription Drugs & Supplements

Do you have any known allergies to medications or herbs?

Yes

Others

If so, please list all:

Are you currently under a practitioner's care for specific health issues?

Yes

Others

If so, what treatments are you undergoing?

Please list any surgeries, accidents, injuries or childhood diseases you have had along with the type and date:

What were your eating habits like as a child? Please list types of food.

What percentage of your food is home-cooked?

How often do you eat out?

What are the three worst foods you eat each week?

What are the three healthiest foods you eat each week?

Do you crave sugar?

Yes

Others

Do you crave salt?

Yes

Others

Do you feel tired, bloated, and/or gassy after meals?

Yes

Others

Do you experience constipation or diarrhea often?

Yes

Others

If so, when and how often?

Do you feel excessively hungry?

Yes

Others

Do you have poor appetite?

Yes

Others

Please indicate family history of:

Diabetes

Kidney disease

Asthma

Heart disease

Arthritis

Gallbladder disease

Stomach/Intestinal Disorder

Cancer (list type of cancer below)

Others

Comments on family health history:

Mother's Age:

Father's Age:

Maternal Grandmother's Age:

Paternal Grandmother's Age:

Maternal Grandfather's Age:

Paternal Grandfather's Age:

Mother died from:

Father died from:

Maternal Grandmother died from:

Paternal Grandmother died from:

Maternal Grandfather died from:

Paternal Grandfather died from:

Approximate age of onset of puberty:

Number of children:

Do you feel your libido is adequate?

Yes

Others

Comments

Do you wake up at night to urinate?

Every night

Sometimes

Never

Others

Comments

Do you have difficulty or pain with urination?

Yes

Sometimes

Others

Are you experiencing diminished volume or flow?

Yes

Sometimes

Others

Do you enjoy daily activities?

Yes

Sometimes

Others

Do you feel apathetic or complacent about previously enjoyed sports, hobbies, clubs, games, etc.?

Do you feel more agitated/irritable than previously?

Please add anything else you wish to share:

Men's Intake Form (NTA)

Palo Alto Nutrition