Graceful Forties Wellness

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Graceful Forties Wellness

Natural Holistic Apothecary

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Client Nutrition Intake Form

Name *

First Name

Last Name

Date Of Birth (Month, Day, and Year): *

Telephone Number: *

Email *

Complete Address (Please Include, City, State, and Zip Code): *

Your Current Weight: *

Subject

What medical concerns (ex. pregnancy), if any, do you have at the present time? *

Indicate if you have had any blood relatives with any of the following: *

Cancer

Diabetes

Heart Disease

High Cholesterol

High Blood Pressure

Osteoporosis

Thyroid Disorder

Do you have complaints about any of the following? *

Appetite

Bleeding Gums

Bruising

Chewing/ Swallowing

Constipation

Diarrhea

Edema

Indigestion

Menstrual Difficulties

Seeing Dim Light

Sudden Weight Change

Stress

Do you use tobacco? If so how much/ how often? *

Do you enjoy physical activity? *

Please list any prescribed over the counter, herbal, or vitamin/ mineral supplements you take: *

Do you follow a special dietary plan for example kosher, vegan, vegetarian, paleo, plant based, whole 30? *

Have you ever followed a special diet? If so, what was your experience? *

Do you have any problems purchasing foods that you want to buy? *

Are there certain foods that you don't like to eat? *

Do you eat at regular times each day? How often do you eat?

Identify any foods you particularly like to eat: *

Do you drink alcohol? How often? How many glasses? *

What changes would you like to make? *

Improve my eating habits

Learn to manage my weight

Improve my activity level

Improve my cholesterol/ triglyceride level

Other

Please add any information that you feel would be relevant to better understanding your nutritional health: *

In order to tailor your nutritional counseling to meet your needs, it will be useful to understand your expectations. Please check one of the following to indicate the amount of structure you believe is right to meet your needs. *

Tell me exactly what to eat for all of my meals and snacks. I want a detailed food plan. Ex. 1/2 C. Oatmeal, 1 C. Almond Milk, 6 Oz. Coffee, 1 slice of Ezekiel Toast, 1 Tsp. Coconut Oil

I want structure, but also freedom to select foods. I want to use the exchange system. Ex. 1 Milk, 2 Servings of Veggies, 1 Fruit, and 1 Healthy Fat

I don't want a diet, I want to make small changes and make food swaps while slowly eliminating unhealthy food choices

What is the highest level of education that you have completed? *

Are you employed? What is your occupation? *

How many people are in your household? What ages? *

Present Relationship Status *

Single

Partnered

Married

Widowed

Separated

Engaged

Divorced

Do you have a refrigerator and stove? *

Who prepares most of the meals in your home? Who does the grocery shopping? *

Do you use convienience food daily? If so which foods and which snacks? *

How often do you eat out and where? *

Have you made any food choices in your life you feel good about? If yes, please share your experience. *

Who can support and help you to make nutrition changes? *

What information would you like from your nutrition counselor? *

Grocery store shopping Tour

Weight Management Recommendations

Time saving food prep

Fiber rich food list

Portion control

Eating out Navigation

Reading food labels

Walking program

Alcohol Nutrition Management

Meal Planning

Snack Planning

Intermittent Fasting Tips

Food Pairing

Timed Eating Routine

✨ Thank you! Please Check your email. You will receive your Fit Mind And Body Weekly Blue Print for your weekly practice today if you have not already received the resource. Please expect to start your practice today! Directions will be included.

Brandi Jackson Wellness

5855 MacArthur BLVD.,

Oakland, CA,

United States

510-731-0049 contact@brandijacksonwellness.com

Hours

Mon 11AM-6PM

Tue Closed

Wed Closed

Thu Closed

Fri 11 AM-6PM

Sat Closed

Sun Closed

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