Please fill out this health questionnaire as best as you can. If there are questions you don't understand or prefer to not answer, we can discuss them during our first meeting. This form should take you about 10-15 minutes to complete. We realize there are a bunch of questions. Each one is important for us. The info helps us to get to know your body, which will assist in steering our recommendations. Thank you very much for taking the time to answer honestly and completely.
Gender * Please select one Female Male Other
How did you hear about us? *
Tell me about your living situation (marital status, kids, roommates, etc.) *
Rate your stress level on a scale of 1–10 (1 being the lowest) *
What are your primary stressors? *
What is your occupation? *
How many hours do you work in a typical week? *
How often do you travel for work? *
Rate your energy level at 9am on a scale of 1–10 (1 being the lowest) *
Rate your energy level at Noon on a scale of 1–10 (1 being the lowest) *
Rate your energy level at 4pm on a scale of 1–10 (1 being the lowest) *
How do you sleep most nights? *
What time do you go to bed? *
What time do you wake up? *
Do you use recreational drugs? How often? *
Tell me about your exercise routine (how often? how long? what type?) *
how would you describe your health in general? *
List any medications you're taking and their use: *
List any supplements your are taking and their use: *
Do you have any aches and pains? If so, please describe. *
when was the last time you were on antibiotics? What were they for? *
Are you currently seeing a mental health practitioner? *
Do you have KNOWN environmental allergies or sensitivities? If yes, please explain. *
Please indicate any of the following that apply to you or anyone in your immediate family:
Describe any other health issues you have.
How often do you have bowel movements? *
If "Other," please explain.
What are your goals for working with a holistic nutritionist? Please list in order of priority: *
Do you have KNOWN food allergies or sensitivities? If yes, please explain. *
Do you drink coffee? if yes, how much per day? *
Do you drink soda? If yes, how much per day? *
How much water do you drink per day? *
Do you drink alcohol? If yes, how much per day? *
List your 10 favorite foods: *
Describe an average breakfast (please be realistic) *
Describe an average lunch *
Describe an average dinner? *
Do you eat snacks during the day? If yes, what times and what do you eat?? *
How ready are you to make changes to your diet and lifestyle? *
How often do you eat fish? *
How often do you eat nuts? *
List the 3 unhealthiest foods you eat during an average week *
List the 3 healthiest foods you eat during an average week *
Are there any foods that you avoid because of the way they make you feel? If yes, please name the foods and symptoms. *
What is your present diet? (AIP, GAPS/SCD, raw, vegan, vegetarian, paleo, refined sugar-free, blood type, gluten-restricted, dairy-restricted, kosher, or no restrictions)? *
Is your current diet working for you? *
Check all of the following that apply to you:
In general, do you eat: *
Who usually prepares your meals at home? *
On workdays, do you bring or lunch or eat out? *
How many meals per week do you eat out of the home? *
How many times do you usually eat per day? *
Women's Health (skip this section if you're male)
Please check all that apply to you:
Office Policies Acknowledgement
Fees:
The initial nutrition visit is $150 per hour (or package price) and includes diet analysis and consultation. Follow-up sessions are 1 hour ($150) OR ½ hour ($95) (or package price). Session fees are paid directly to Healthy Nest Nutrition, LLC . Payment is due at time of service unless prior arrangements have been made. Payment can be made by cash or check or credit card. There will be a $25.00 charge for all returned checks. Packages:
Prepaid packages are discounted from individual session prices Prepaid packages are non-refundable Program packages are a combination of sessions, are discounted off individual sessions, and are available for hour-long, ½ hours & a combination, depending on the particular package.
Insurance:
Healthy Nest Nutrition does not accept insurance, but can use most health care flex spending account money for nutrition services Missed Appointments:
A 24-hour notice for cancellations is required for missed sessions. Late appointments will not be extended and the fee for the original session will be charged. No-show sessions will be charged at full price Medical Grade Supplements:
All supplements must be paid for at time of purchase. Unopened supplements can be returned for full refund within 60 days of purchase. Supplements are not included in the session fees. Initial here to acknowledge that you have read and agree to the above office policies. *
Read the following statement and initial below:
understand that Healthy Nest Nutrition, LLC (Healthy Nest Nutrition) will provide me with professional nutritional evaluation, therapy, and support for the purpose of enhancing my health (Nutrition Therapy). I understand that Nutrition Therapy is not intended as a diagnosis, treatment, prescription or cure for any disease, mental or physical, and is not intended as a substitute for regular medical care. In Nutrition Therapy there are no medical procedures performed and medications are not prescribed. I understand that Nutrition Therapy services will be provided by Robin Hutchinson who is a Master Nutrition Therapist and has completed two years of schooling at The Nutrition Therapy Institute, an accredited Nutrition Therapy College. I understand Robin Hutchinson is not a physician licensed pursuant to Article 36 of C.R.S. Title 12, nor licensed, certified, or registered by the State of Colorado as a health care professional and I should discuss any recommendations made by Healthy Nest Nutrition with my primary care physician, obstetrician, gynecologist, oncologist, cardiologist, pediatrician or other board-certified physician. I release Healthy Nest Nutrition from any liability for my health issues. I have truthfully completed the Client Intake Form for Healthy Nest Nutrition and listed all my known physical and medical conditions, as well as any medications and supplements that I am taking and I will keep Healthy Nest Nutrition informed of any changes. I agree to pay Healthy Nest Nutrition's rates, which are outlined in the attached fee schedule. Healthy Nest Nutrition does not accept health care insurance. Healthy Nest Nutrition is covered by liability insurance applicable to any injury caused by an act or omission by its provision of alternative health care services. This agreement and release is being signed voluntarily and not under duress of any kind.
Initial here to acknowledge that you have read and agree to the above statement. *
by signing below, I agree that all the information I have provided is true.
