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Intake Nutrition
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Intake Nutrition
Intake Nutrition
developer
2023-02-10T03:49:07-05:00
Name
(Required)
Date
MM slash DD slash YYYY
Address
Phone Number
(Required)
Age
Email
(Required)
Date Of Birth
MM slash DD slash YYYY
What are your Major Complaints
Problem 1
Severity: Mild Moderate or Severe
Prior Treatment 1
Success: Excellent, Good, Fair
Do you have more complaints?
Yes
No
Problem 2
Severity: Mild Moderate or Severe
Prior Treatment 2
Success: Excellent, Good, Fair
Problem 3
Severity: Mild Moderate or Severe
Prior Treatment 3
Success: Excellent, Good, Fair
Problem 4
Severity: Mild Moderate or Severe
Prior Treatment 4
Success: Excellent, Good, Fair
Have you used any of the following for a prolonged period?
NSAIDS (Advil, Aleve, Motrin, Aspirin)?
Tylenol Acetaminophen
Acid blocking drugs: (Zantac, Prilosec, Nexium, etc. (40mg/ day)
Allergies
Allergen (medication, food, environmental)
Reaction
List your medications and supplements. Include doses if possible
Medicine/ Supplement
Brand
Dose
Frequency
Indication
More medications and supplements?
Yes
No
Medicine/ Supplement
Brand
Dose
Frequency
Indication
Medicine/ Supplement
Brand
Dose
Frequency
Indication
Medicine/ Supplement
Brand
Dose
Frequency
Indication
How much sleep do you get each night on average?
Do you have trouble
Falling asleep
Waking at night (3x)
Falling back to sleep
Feeling rested in morning
Snoring
Breathing
List any food allergies, sensitivities or aversions?
How many meals do you eat a day?
What do you eat for: Breakfast
What do you eat for: Lunch
What do you eat for: Dinner
What do you eat for: Snacks
How often do you eat?
Are there foods you eat on a daily/almost daily basis?
Do you use sweeteners?
How often do you eat out per week?
How much water do you drink each day?
What is your smoking/vaping history?
History of alcohol use?
History of caffeine use?
What emotional stressors do you have now
How do you deal with Stress?
Your exercise?
General fitness
Endurance
Muscle training
Weight loss
Osteoporosis prevention
Specific sport enhancement
Coordination/balance
Flexibility
Other
Describe your exercise?
Do you use any of the following
Water filter
HEPA air filter
Non-toxic cleaning products
Non-toxic personal products
Organic when possible
Non-toxic laundry detergent
Non-toxic makeup
Aluminum-free, non-toxic deodorant
EMF protection
I agree
(Required)
I understand that all nutritional recommendations are recommendations meant to support general nutrition within the scope of a licensed RN and certified nutritionist. I understand that Georgina McNiff, RN is not diagnosing or treating any diseases or conditions. I authorize Nurse Georgie Health to charge my credit card on file after each appointment
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