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    Brooklyn, New York, 11235
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PATIENT NUTRITION HEALTH ASSESSMENT FORM

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NUTRITION HEALTH ASSESSMENT FORM
MEDICAL HISTORY:(CHECK ALL THAT APPLY)
WOMEN
FAMILY HISTORY
LIFESTYLE ~ PHYSICAL ACTIVITY
STRETCHING / YOGA
CARDIO / AEROBICS (WALKING, JOGGING, BIKING, ETC.)
STRENGTH-TRAINING (WEIGHTLIFTING, PILATES, SOME YOGA)
SPORTS OR LEISURE
OTHER (SPECIFY/DESCRIBE)
INDICATE DAILY STRESSORS AND RATE THE LEVEL OF STRESS FROM 1 (EXTREMELY LOW) TO 10 (EXTREMELY HIGH):
ON AVERAGE, HOW MANY HOURS OF SLEEP DO YOU GET?
DO YOU SMOKE?
DO YOU DRINK ALCOHOL?
WEIGHT HISTORY:
DIGESTIVE HISTORY
PLEASE CHECK ANY OF THE SYMPTOMS YOU EXPERIENCE ON A REGULAR BASIS. CHECK ALL THAT APPLY.
DIET HISTORY
INTAKE INFORMATION:
PLEASE CHECK ANY OF THE FOLLOWING THAT DESCRIBE YOUR CURRENT INTAKE:
CHECK ALL THAT APPLY:
HOW WOULD YOU DESCRIBE YOUR EATING HABITS?CHECK ALL THAT APPLY:
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