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Complaints/Concerns/Goals
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Digestive Health:
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Energy (1-10, 10 being the highest) - Energy Throughout the day
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Sleep
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Bedtime Routine
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Hours
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Sleep - Quality
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Stress (1-10, 10 being the highest)
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Work
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Personal
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Stress reduction techniques
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Relationships/Support
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Relationships/Support - Notes:
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Exercise
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How many days per week?
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Types of exercise
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Do you enjoy exercising?
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Diet/Nutrition
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Allergies to food
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Aversions to foods
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Specific dietary guidelines you follow
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Liquids: How much per day/week?
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Water
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Coffee
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Alcohol
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Soda
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Juice
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Milk
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Example Meals
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Breakfast
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Lunch
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Dinner
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Snacks
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Protein:
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Grains
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Dairy
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Legumes/Beans
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Nuts/Seeds
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Fruits/Vegetables
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