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What is the reason for your appointment?

How did you hear about Nutrition with Jan Marie?

Health Information. Please list any medical/health conditions

Please list any major operations you have undergone.

Please list any current prescription medications & reason for taking them.

Please list any current nutrition supplements (herbs/vitamins/minerals etc).

Current weight if known approx (kg)

Height if known approx (cm)

Please indicate how often you pass a bowel motion. Daily? How often?

Please indicate if you regualry experience (hard stools, loose stools, watery stools) if so how often?

Do you experience bloating? If so how often? List any foods you are aware that may cause this.

How would you rate your energy levels? Low/Moderate/High?

Do you fall asleep easily at night? Yes/No

On average, how many hours do you sleep at night?

Do you currently have a lot of stress in your life?

Do you smoke?

Do you exercise regularly? Yes / No If yes, what type(s) of exercise?

How many days per week do you exercise?

On average, how much water do you consume each day? Type? Filtered? Tap?

If you consume alcohol, how much do you consume?

Notes