Nutritional Analysis History Form

HTML

Personal Information

Full Name *

Age *

Gender *MaleFemaleOther

Height *

Weight *

Occupation *0 / 20

Phone *

Email Address *

Emergency Contact Full Name *

Emergency Phone Number *

HTML

Health History

Do you have any existing medical conditions? *YesNo(e.g., diabetes, hypertension, heart disease, etc.)

If yes, please specify *

Have you ever been diagnosed with any nutritional deficiencies or eating disorders? *YesNo

If yes, please specify *

Are you currently on any medications or supplements? *YesNo

If yes, please specify *

Have you had any surgeries or major health events in the past? *YesNo

If yes, please specify *

Do you have any food allergies or intolerances? *YesNo

If yes, please specify *

Do you have any dietary restrictions? *YesNo(e.g., vegetarian, vegan, gluten-free, etc.)

If yes, please specify *

HTML

Diet for Clinical Conditions

Have you been diagnosed with any of the following clinical conditions? *(Please check all that apply)

If other, please specify *

Have you been diagnosed with any of the following clinical conditions?

If yes, please specify *

Are you currently following a specific diet plan or guidelines prescribed by your healthcare provider for your condition(s)?If yes, please describe the diet (e.g., low-sodium, low-sugar, low-fat, gluten-free, etc.)

If yes, please specify *

Do you have any specific food restrictions or recommendations due to your medical conditions?

If yes, please specify *

Are you monitoring or controlling any of the following as part of your treatment plan? *(Check all that apply)

If other, please specify *

Are you experiencing any of the following challenges in following a prescribed diet for your condition? *(Check all that apply)

If other, please specify *

HTML

Dietary Habits & Preferences

How many meals do you typically eat per day? *1-23More than 3

Do you snack between meals? *YesNoIf yes, what kinds of snacks do you typically eat?

If Yes, please specify *

What is your typical breakfast? (Include portion sizes, if possible) *

What is your typical lunch? (Include portion sizes, if possible) *

What is your typical dinner? (Include portion sizes, if possible) *

How many servings of fruits and vegetables do you eat per day? *1-23-45+

How much water do you drink per day? *0-2 cups3-5 cups6+ cups

Do you consume alcohol? *YesNo

If yes, how often and how much? *

Do you drink caffeinated beverages? *YesNo(e.g., coffee, tea, energy drinks)

If yes, how often and how much? *

HTML

Physical Activity

Do you exercise regularly? *YesNo

If yes, how often and what types of exercises do you do? *

Do you engage in any sports or physical activities? *YesNo

If yes, how often and how much? *

How would you rate your activity level? *

What is the intensity of your usual exercise routine? *

On average, how long is your workout/session? *

HTML

Sleep Habits

On average, how many hours of sleep do you get each night? *Less than 5 hours5-6 hours7-8 hoursMore than 8 hours

Do you have trouble falling asleep or staying asleep? *YesNo

If yes, please describe *

Do you have a consistent sleep schedule? *YesNo(e.g., same bedtime/wake time each day)

If yes, please explain *

Do you take naps during the day? *YesNo

If yes, how long are your naps *

Do you have any sleep disturbances? *YesNo(e.g., snoring, sleep apnea, restless leg syndrome, etc.)

If yes, please specify *

HTML

Stress Factors

Do you experience stress on a regular basis? *YesNo

If yes, please describe the sources of stress (e.g., work, family, financial, health- related, etc.) *

How would you rate your general stress level? *LowModerateHighVery High

How do you typically respond to stress? *Eating more foodEating less foodExercisingSleeping more/lessUsing stress-relieving activities (e.g., meditation, reading, etc.)Avoiding stressors (e.g., withdrawing, procrastinating)Other (please specify)

If Other (please specify) *

Do you experience any of the following physical symptoms when stressed? *HeadachesDigestive issues (e.g., bloating, stomach aches, nausea)FatigueSleep disturbancesWeight changes (gain or loss)Increased heart rateTension or muscle painOther (please specify)(Check all that apply)

Other (please specify) *

Have you been under any major sources of stress recently ? *YesNo(e.g., life events, job changes, personal challenges)

If yes, please specify *

Do you have any coping mechanisms for stress that help you feel better or more balanced? *YesNo

If yes, please list *

Do you feel that your stress level is affecting your overall health or well-being? *YesNo

If yes, please describe how *

HTML

Stress-Relieving Activities

Which of the following activities help you relieve stress? *(Select all that apply)

Other (please specify) *

How often do you engage in these activities? *

Do you feel that stress or emotional factors affect your eating habits? *

If yes, how do they affect you? *

HTML

Cravings and Aversions

Do you experience cravings for certain foods? *YesNo

If yes, please specify the types of foods you crave *

Are there any foods you actively avoid or dislike? *YesNo

If yes, please specify *

Do you have a preference for sweet, salty, or Savory foods? *SweetSaltySavoryNo preference

Do you ever eat because of emotional reasons? *YesNo(e.g., stress, boredom, sadness)

If yes, how often does this happen? *

HTML

Goals & Preferences

What are your health and nutrition goals? *

Other (please specify) *

Do you have any food preferences or dislikes? *YesNo

If yes, please list *

Are you interested in receiving meal plans, recipes, or nutrition tips? *YesNo

Do you need assistance with meal prepping or portion control? *YesNo

HTML

Additional Information

Is there anything else you would like to share about your health, diet, or lifestyle? *