Nourishing Wisdom: Nutrition Counselor and Natural Skin Care Products

About You

Name:		Session date:
Address:
City:		State:	Zip Code:
Home Phone		Work Phone:
Cell Phone:		Email:
How often do you check your email?
Age:	Date of Birth:	Place of Birth:
Current Weight: 6 Months Ago: One Year Ago:
Would you like your weight to be different? Yes No
If so, how?
Relationship Status:		Children?
Occupation:		How many hours a week do you work?
Do you sleep well? Yes No	Do you wake up a night? Yes No	What time(s)?	To urinate? Yes No
What time do you generally get up in the mornings? What time do you generally go to sleep at night?		Any constipation or diarrhea? Sensitivities or allergies to foods?
Blood Type (if known)
When was your last dental cleaning? Last dental visit?
Do you floss? Yes No Do you use an electric toothbrush? Yes No Waterpick? Yes No

Your Lifestyle

What role does exercise play in your life?
Do you take any herbs/ vitamins / medications regularly? Yes No If so, which? (please list all of them)
What percentage of your food is home cooked?		Where do you get the rest from?
Are there any other healers, helpers or therapies with which you are involved? Yes No Please list:


What are your main health concerns?
Other concerns?

Do you have sweet cravings? Yes No If yes, for what and what time of the day do they occur?
How often do you drink coffee?	How often do you smoke?	How often do you eat chocolate?	How often do you drink alcohol?

Do you use a microwave on a regular basis?

Do you use non-toxic home cleaning products?

Do you use non-toxic personal care products (cosmetics, skincare, toothcare…)

For Women

How many days is your flow?
How many days is your cycle?
Painful or Symptomatic? Yes No
If yes, please explain:
Are you in menopause? Yes No
If yes, how has your transition been?

What foods did you eat often as a child?

What about a year ago? (Provide sample meals)

What's your food intake like these days? (Provide sample meals)

Simple Pleasures

What magazines do you subscribe to?

How much television do you watch daily?

Do you spend time outdoors daily?

Do you take baths?

What activities do you do that bring you joy?

Do you meditate or have a spiritual practice?

Is there any other information that would like us to know?

Family Health


How is the health of your mother?

How is the health of your father?

Do you have siblings? Yes No
If so, how is their health?

Holly Anne Shelowitz Email: info@nourishingwisdom.com Phone: 845.687.9666