Take The Quiz - Primal Complete

Quiz Form

First Name

Last Name

Contact (phone/email

Date of Birth

Please list your current and existing complaints according to their priority level (describe problem in detail):

Please specifiy any allergies you are aware of and reactions:

If any of the above pertained to you please specify ailment and diagnoses:

Women's Reproductive Disorders or Hormonal Imbalances - if applicable, please describe issue

Men's Hormonal Imbalances, Prostate issues or ED - if applicable, please describe issue

Gi History (foreign travel, wilderness camping, severe diarrhea, or parasites) - please specify issues

Are you currently taking any medications? Please specify

Are you currently taking any nutritional supplements? Please specify

Are you currently using any herbs or homeopathy? Please specify

Have you ever had prolonged or regular use of antidepressants, anti-inflammatories, antacids, steroids, or antibiotics? (>3x's per year)? If yes please specify which medication, dates, and describe length or use and any side effects.

Have you ever had a nutrition consultation?

Yes

Do you AVOID any particular food?

Yes

Maybe

If you could only eat a few foods each week, what would they be? (*Three Favorite foods)

Do you grocery shop?

Yes

Do you read food labels?

Yes

if you do read labels, what are you looking for?

Do you cook?

Yes

How many meals do you eat out per week?

0-1

2-3

4-5

5-6

Do you consume soda pop, fruit juice or trendy beverages sweetened with sugar or fruit juice?

None

1-2x per week

3-4x per week

5 per week

Food Journal - let me know what your typical daily food choices/preferences

One food habit or lifestyle choice that you know does not support your health, that you would like to change:

Do you currently smoke (tobacco, marijuana, vape)?

Yes

Do you consume alcohol?

Yes

Do you consume other substances?

Coffee

Caffeinated Sodas

Energy drinks

Other

Do you have a exercise program currently? If so, what are you doing?

Do you have any known food related intolerances, sensitives, allergies or serious adverse reactions?

In your workplace or home, have you ever been exposed to or are currently exposed to:

Industrial chemicals

Electromagnetic Radiation

Mold

Other

Do you dry clean your clothes?

Yes

Do you have pets?

Yes

Please provide a look into what your food intake looks like during the week? You can write it like a food journal.

Nutritional Assessment Intake

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