Koru Nutrition Assessment Step 1 of 7 14% Name* First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home PhoneCell PhoneEmail* Occupation*Date of Birth* MM DD YYYY Age*Gender*MaleFemaleCurrent Height*Current Weight*Blood Type (if known)ABABONutrition Goals? Why are you seeking nutrition counselling?Please list your health concerns in order of importance to you that you would like addressed.Indicate any treatment or testing you have had and are currently receiving for any of these concerns.Have you had any recent blood work or tests completed?*NoYesIf yes, what were the results?*What other health providers do you see?How did you hear about us? PERSONAL MEDICAL HISTORYPlease check the conditions you have had or currently have. Please indicate in the box next to the condition whether this is a past condition or current condition and any further details you wish to provide. Acne ADD/ADHD Adrenal Fatigue Alzheimers Alcoholism Allergies Anemia Angina / Heart Attack Anxiety Appendicitis Arthritis Asthma Autism Autoimmune Bipolar Disorder Brain injury/concussion Cancer Candida Celiac Disease Chicken Pox Chronic Bronchitis Chronic Fatigue Colitis / Crohn's Depression Dementia Diabetes Digestive Issues Drug Abuse Easy Bleeding / Bruising Eczema Emphysema/COPD Endometriosis Enlarged Prostate Epilepsy Fibromyalgia Food Sensitivities Gallstones German Measles Gout Headaches/Migraine Heart Disease Heart Murmer Hemorrhoids Hepatitis High Blood Pressure High Cholesterol HIV Hives HPV Hyperthyroidism Hypothyroid IBS Irregular Menses Kidney Disease Kidney Stones Liver Disease Jaundice Low Blood Pressure Lupus Lyme Disease Measles Memory Loss Meningitis Mental Illness Miscarriage Mononucleosis Multiple Sclerosis Mumps Nerve Damage Osteoporosis Overweight Parasites Parkinson's Pelvic Inflammatory Disease Peritonitis Pneumonia Pressure sore Polycystic Ovaries Psoriasis PTSD Rheumatic Fever Rheumatism Roseola Rubella Schizophrenia Shingles Seizures / Convulsions Sickle Cell Anemia Strep Throat Stroke Syphillis Thyroid Tuberculosis Ulcers Underweight Varicose Veins Please elaborate on any of the conditions that you ticked above that you think would be pertinent for your nutritionist to know or in relation to your current health goals.Please list any additional conditions not found in the options above.Please list any major trauma, stresses or injury, or accident you have experienced in your life. Please be as specific as possible with date, trauma and long term effects.Please list any surgical procedures you have undergone. Please be as specific as possible with date, type of procedure and results/complications.Please list any other forms of treatment that you have used and describe their effectiveness. Please include dates where possible.Additional comments regarding your Medical History: MEDICATION AND SUPPLEMENTSPlease list any prescription medications, over-the-counter medications, vitamins or other supplements you are currently taking. Please include dosages, and reason for use.Remember to include: appetite suppressants, antacids, laxatives, pain relievers, cortisone/prednisone, nasal decongestants tranquilizers, anti-depressants, sleeping pills, hormones, birth control pills, drugs, herbs, minerals, homeopathies, bach flower remedies, Chinese herbal remedies, and anything else you take regularly or are currently on. Medication or SupplementDosage and frequency of taking itPurpose FAMILY MEDICAL HISTORYPlease indicate any health conditions in your family: Cancer Heart Disease Arthritis Glaucoma Tuberculosis Diabetes Asthma Allergies Hay Fever / Hives Food Sensitivities Digestive Issues Celiac Disease Crohn's / Colitis Thyroid Problems Autoimmune Kidney Disease Depression / Anxiety Neurological Disease Mental Illness Anemia Stroke Seizures / Epilepsy High Blood Pressure Please indicate if there is any other family history health issues that were not identified above and elaborate on health conditions identified above if able.WORK AND LIFESTYLEDo you smoke cigarettes or cigars, if so how often?Do you use marijuana ort medicinal marijuana and if so how often?Do you use any other recreational drugs currently, or in the past?PastCurrentlyNoDo you consume alcohol? If so what alcohol do you consume and how often?Who do you live with?(Spouse, children and their ages)What exercise or healthy lifestyle practise do you implement in your current lifestyle ie please include exercise regime, stress management strategies etc?Do you have any barriers or difficulties with implementing nutrition changes when you have tried in the past or what you for see will be issues currently?StressDo you have any sleep difficulties? Please indicate with the following: Getting to sleep Remaining asleep Nightmares Frequent waking How do you feel when you wake up in the morning?How many hours do you get of sleep a night?What time do you got to bed?What time do you wake up?Do you snore?NoYesDo you take any sleep aids, if so what?Energy LevelsHow would you describe your energy levels?What would you rate them out of a scale of 1 to 10?(with 1 indicating having limited energy)WeightAny recent weight changes?If weight gain is the issue where about's on the body do you put on weight?(Hips, thighs, stomach, back of arms, buttocks, back "bra fat" etc.)Goal weight?(if you have one) MEAL PREPARATIONWho is responsible for the meal preparation at home?Do you have any difficulties with preparing meals at home?Who does the grocery shopping?Do you have a grocery budget? If so, what is this?What appliances do you have access to in your home? Blender Crock pot/slow cooker Microwave Stove Oven Bench top oven BBQ How often do you use these appliances?DIGESTIONBowelsHow often do you have a bowel movement?Is it a strain to pass?NoYesWhat colour is your stool?(Chocolate brown, green, yellow/clay color, black or other?)Have there been any recent changes in the frequency of your bowel movements?Do you have a tendency to develop constipation?NoYesDo you have a tendency to develop diarrhea?NoYesBlood in stool?NoYesDo you struggle with any of the following? Diverticulitis Fissures Fistulae Anal Pain Have you been on antibiotics in the last 5 years?(If yes, how long or how often?)GastrointestinalDo you have any issues with digestion for the following? Abdominal pain Belching / Passing gas Bloating Decreased appetite Increased appetite Decreased thirst Increased thirst Heartburn Hemorrhoids Indigestion Intestinal worms Irritable bowel syndrome Liver / Gallbladder disease Liver Disease / Jaundice Pancreatitis Nausea / Vomiting Nervous stomach Rectal bleeding Ulcers If yes, do you know what triggers this? Please explain: FOOD & DIETHow many cups do you have of the following, on average, each day? How do you drink it? (ie with milk and sugar etc?)WaterCoffeeTeaPopJuiceSports DrinksMilkWhat other beverages do you drink, and how much?Do you prefer your beverages cold, neutral, or hot?Do you follow a special kind of diet or consume a specific cultural diet?Vegan, vegetarian, ketogenic, diabetic, Indian, Muslim etc?How many times per week do you consume wheat?How many times per week do you consume dairy products?How many times per week do you consume red meat?How many times per week do you eat breakfast?How many times per week do you eat lunch?How many times per week do you eat dinner?If you miss any of the above meals, what is the reason for this?If you miss meals do you feel any symptoms such as irritable, dizziness, fatigue, hungry, reduced concentration, sleep difficulties etc?List the primary foods/meals included in your diet for BREAKFAST:List the primary foods/meals included in your diet for LUNCH:List the primary foods/meals included in your diet for DINNER:List the primary foods/meals included in your diet for SNACKS:Are there any foods you don't like or exclude from your diet, or do you restrict your diet in any way, if so, what foods and why?Are there any foods that you crave or love specifically?Chocolate, sweets, salty, sour, rich/fatty, breads, spicy.How often do you go on a diet? If so what kinds of diet(s) have you done and what success have you had?Do you have, or have you ever had an eating disorder?NoYesAny issues with eating certain textures?Are your eating habits affected by emotions?Example: When you are stressed or depressed do you over eat or eat more junk food or do you avoid food altogether? Please explain.Additional comments regarding food and eating habits? CURRENT HEALTH ISSUESSkinAny skin issues in relation to acne, rosacea, dry skin, athlete's foot, boils, bruise easily, eczema, hives, itching or melanoma & other skin cancer, psoriasis, rashes, pressure sores, or open wounds?Please indicate what you suffer from?HairAny hair issues with coarse, brittle, dry hair, hair loss, or dandruff?If so, please explain:NailAny issues with nail changes, break easily, or crack?If so, please explain:EarAny issues with discharge (ears), dizziness, tinnitus, hearing loss, earache, excess ear wax, ear infections?If so, please explain:EyesAny issues with blind spot, blurred vision, cataracts, double vision, eyes dryness or pain, glaucoma, itchy eyes, macular degeneration, vision changes, or other visual Impairment?If so, please explain:MouthAny issues with canker sores, dental cavities, dry mouth, bad breath, gum problems, gingivitis, mouth sores, teeth grinding, any teeth removed if so how many, other teeth/gum or mouth problems?If so, please explain:Eating & FeedingAny difficulties with chewing, swallowing, choking, TMJ/jaw pain, using a knife and fork/chopsticks?If so, please explain:Do you have excessive hunger or no appetite?Do you have issues with portion control?Sickness / FluAny issues with frequent colds, frequent sore throats, or frequent infections?If so, please explain:Taste & SmellAny issues with sense of smell and taste?If so, please explain:Sinus / Mucous CongestionAny issues with post nasal drip, ringing in ears, sinus problems/Infections, stuffiness, hay fever, or sputum?If so, please explain:RespiratoryAny issues with bronchitis, asthma, cough, difficulty breathing, emphysema/COPD, shortness of breath, tuberculosis, or wheezing?If so, please explain:CardiovascularAny issues with angina/heart attack, chest pain, heart disease, high blood pressure, low blood pressure, palpitations, fluttering, swelling in ankles or edema/water retention?If so, please explain:UrinaryAny issues with blood in urine, difficulty urinating, frequent urinary Infections, inability to hold urine, increased urination frequency, kidney stones, or pain on urination?If so, please explain:Men's HealthDo you have any issues with discharge or sores, hernia, sexual difficulties, testicular pain, prostate issues?If so, please explain:Women's HealthDo you have any issues with bleeding between cycles, difficulty conceiving, excessive bleeding, fibroids, hysterectomy, irregular Cycles, menopause, PMS, vaginal discharge, vaginal itching?If so, please explain:Are you on birth control pills?NoYesMusculoskeletalDo you have any issues with arthritis, backache, bone/joint disease, fractures, bursitis, chest/rib pain, foot or hand pain, hip pain, joint pain/stiffness, leg pain, lower, mid or upper back pain, neck pain, shoulder or arm pain, strains or sprains, muscle spasms or cramps, muscle weakness or pain?If so, please explain:Do you have any issues with walking, scoliosis, muscle loss, low muscle tone, strength changes, tendonitis?If so, please explain:HeadachesDo you have issues with headaches?If so, how often?What triggers them?How long do they last?What do you do to get relief?Peripheral / VascularDo you have any issues with cold hands/feet, tingling/numbness in extremities, coldness or swelling in extremities, varicose veins, anemia, blood transfusions, easy bleeding/bruising?If so, please explain:NeurologicalDo you have any issues with fainting, involuntary movement, loss of balance, memory, paralysis, seizures/convulsions, shaking, speech problems, struggle with word finding, or vertigo?If so, please explain:EmotionalDo you have any issues with alcoholism, anxiety, nervousness, tension, depression, mood swings or phobias?If so, please explain:HormonalDo you have any changes in weight, can't lose baby weight, diabetes, excessive sweating, excessive thirst, excessive urination, feel hot/cold, hormonal therapy, hypoglycemia (low blood sugar), poor concentration, sluggish after exercise, thyroid abnormalities?If so, please explain:Are you trying to get pregnant or currently pregnant?Please provide details on above conditions, or describe any other conditions you may have that are not included in the table above. Client Acknowledgement / Disclaimer FormAccuracy of Information*I certify that the above medical and personal information is correct to my knowledge. I agree Privacy and Sharing of Information*I authorize Koru Nutrition Inc and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize Koru Nutrition Inc and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission. I have read and agree Disclaimer of Health Related Services*This clinician encourages the client to continue to visit and to be treated by his/her healthcare professionals, including, without limitation, a physician and that the nutritional advice that the client receives is not to be seen as medical advice and is not to take the place of seeing your licensed health professional. The client understands that this clinician is not acting in the capacity of a doctor, psychologist or other licensed or regulated professional. Accordingly, the client understands that this clinician is not providing health care, medical or therapy services and will not diagnose, treat or cure in any manner whatsoever any disease, condition or other physical or mental ailment of the human body. The client understands that this clinician will not complete any licensed or controlled acts which may constitute the practise of medicine. Only a licensed physician can prescribe drugs. Any mention of drugs in the course of consultation is only for the purpose of providing a complete history of drugs that the client is taking and not for this nutritionist to judge the appropriateness of the medication. Any change in prescription or dosage is a decision the client makes with his or her physician. I have read and agree Personal Responsibility and Release of Health Care Claims*The client expressly assumes the risks of the program, whether or not such risks were created or exacerbated by this clinician. The client releases this clinician, administrators, director, shareholders and Koru nutrition (collectively, the Releasees) from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law, admiralty or equity, which against the Releasees, the client ever had, now has or will have in the future against the Releasees, arising from the client's past or future participation in, or otherwise with respect to, the nutrition program, unless arising from the gross negligence of the Releases. I have read and agree Medical or Insurance Letter Policy*Koru Nutrition inc does not bill time required to communicate with your other health care practitioners or insurance companies. We believe this is an important part of your health care and value being apart of your health care team. If clients require a letter or paperwork for any reason, clients will be invoiced for the time. I have read and agree Insurance Submissions and Invoice Policy*Clients are responsible for maintaining and submitting required receipts to their insurance company for reimbursement of services. All invoices are sent to clients electronically to create a permanent file for clients to maintain. I have read and agree Consent to Nutrition Counseling Policy*By agreeing, you understand that by working with Koru Nutrition inc you will be fully informed regarding your nutrition plan, possible side effects, expected outcomes and possible alternative treatments available. We do not guarantee treatment results, and you have the ability to withdraw your consent to services at any time. You also acknowledge that you have the right to ask questions, and be involved in your nutrition program and process. Our model is to provide client-centered health care with informed decision making as a priority. I have read the consent to nutrition counselling policy and understand I will be informed of the particular risks and benefits of my nutrition program. Payment for Services*Payment for services is due prior to the first consultation session and a receipt will be given when payment is received. Please retain this receipt for your insurance or income tax claims, if applicable. Fees may be paid in by Visa or MasterCard. Please note that refunds are not available for nutrition services rendered, including lab tests performed. Extended health benefit plans may provide coverage for nutritionists or registered Dietitians. Plans and policies differ, so please check with your provider regarding coverage and claim procedures. I have read and agree to the policy on Payment for Services. Dispensary and Natural Health Products*Your practitioner may recommend that you take certain products as part of your nutrition program. Koru Nutrition stocks many supplements on their online dispensary, but please note that you are free to choose where you purchase the recommended products. I agree with the policy on Dispensary and Natural Health Products. CAPTCHANameThis field is for validation purposes and should be left unchanged.