Integrative Health Providers | Nutrition Form

Do you have allergies or sensitivities to nuts, soy, oats, celery or other foods?

Yes

No

Are you pregnant or nursing?

Yes

No

Do you have a fever, cough, diarrhea, or signs of an active infection?

Yes

No

Have you had baseline labs drawn within the past 12 months?

Yes

No

Do you have a history of fainting?

Yes

No

What is your activity level?

Sedentary

Lightly Active (light exercise 1-3 X per week)

Moderately Active (Moderate exercise 3-5 X per week)

Very Active (Strenuous exercise or very physical job daily)

Do you have any chronic diseases that you take medications for such as Diabetes, Heart Disease, Thyroid Disease, Liver Disease, Kidney Disease, or Cancer?

Yes

No

Preferred communication:

Email

Phone

Evidence-Based Nutrition