Lifestyle Assessment Form : Miranda Malisani

Personal Details
Name*
First Last
Age*
Sex*
- Male
- Female
General Health
What is your current weight?*
What is your purpose in coming here today?*
What are your main health concerns/complaints?*
Have you ever been diagnosed with an ailment related to your main health concern(s)?*
Any trauma or loss in the last 5 years?*

Family History
Hereditary Diseases: Please tell me about your family's medical history by inserting the following: 'F' for father, 'M' for mother, 'S' for sibling, 'G' for grandparent, 'O' for others.
Heart Disease
Diabetes
Allergies
Hypertension
Arthritis
Mental Illness
Intestinal Disease
Osteoporosis
Alcoholism
Kidney Dysfunction
Ulcers
Asthma
Gall Bladder Problems
Cancer (Please detail type):
Other (Please list):

Females Only
Please only fill out this section if you are female. If you are male please select n/a for each question.
Are you currently pregnant or nursing?*
- Yes
- No
- n/a
Please give details
Are you pre-menopausal or menopausal?*
- Yes
- No
- n/a
Are you experiencing any menopausal symptoms?*
- Yes
- No
- n/a
If yes, please specify:
Have you had a bone density test? Yes or No? If yes, what was the result?*

Dietary Habits
How many times a day do you eat:
- Main Meals:*
- Snacks:*
Do you eat meals:*
- With Family
- Home Alone
- On the Run
- In a Restaurant
- Fast Food
Do you feel there are restrictions to your diet due to the preferences of others - Family, roommates, etc? Yes or No? If yes, explain*
How many ½ cup servings of each do you typically eat in a day:
Fruit: Fresh / Dried / Canned*
Vegetables: Cooked / Raw*
Whole Grains*
Protein (Please list type also):*
Dairy Products (Please list type also):*
Other (Please specify):*
Give examples of your typical meals:
Breakfast:*
Lunch:*
Dinner:*
Snacks:*

Are you a:*
- Meat Eater
- Vegetarian
- Vegan
How often do you eat meat?*
- Daily
- 3-5 times a week
- One a week or less
How often do you consume dairy products?*
- Daily
- 3-5 times a week
- Once a week or less
What are your favourite foods?*
How often do you eat them?*
Do you avoid certain foods? If so, why?*
Do you experience any symptoms if meals are missed? Explain:*
Do you experience any symptoms after meals? Explain:*
Any additional comments:

Client Statement
I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being, and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily.
Date*
Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Email*
Enter Email Confirm Email
Thank you for your cooperation. All information contained on this form will be kept strictly confidential.

Miranda Malisani – Nutrition Expert