Certified Nutritionist
Corrective Exercise Specialist
Strength & Conditioning Specialist
Name Birthdate Home Phone
Address City Cell Phone
State Zip Email
Occupation How long? Work Phone
Address City Work Email
State Zip Website

Reason for Consult: (Please be specific about your current health concerns and goals)
Sex... ...Height.. ...Current weight.
Do you have any of the following.
Acne Cold Sores Hiatal Hernia Lung Disease
ADD (attention deficit disorder) Colitis (ulcerative) Hives Lyme Disease
AIDS Constipation Hot Flashes Macular Degeneration
Alcoholism Coronary Artery Disease (CAD) Hypoglycemia Migraines
Amenorrhea Crohn’s Disease Hyperglycemia Mitral Valve Prolapse
Anemia Cystic Fibrosis Hypertension Multiple Sclerosis
Angina Pectoris Depression Hyperthyroidism Nausea
Anxiety Dermatitis Hypochlorhydria Nervousness
Arrythmia Diabetes: (Type I or Type II) Hypoglycemia Osteoarthritis
Arteriosclerosis Diverticulosis Hypotension Osteoporosis
Arthritis Ear Infections Hypothyroidism Pancreatitis
Asthma Eczema Impotency Parkinson’s Disease
Bleeding Gums Endometriosis Incontinence Peptic Ulcer
Bone Spurs Epstein Barr Virus Infertility (female) Prostate Problem
Bradycardia Fibromyalgia Infertility (male) Psoriasis
Bronchitis Fungal Infections Insomnia Sciatica
Bruxism Gall Stones Interstitial Cystitis Stroke
Bursitis Glaucoma Irritable Bowel Syndrome Tachycardia
Cancer Goiter Kidney Disease Thrush
Canker Sores Gout Kidney Stones Thyroid Related Illness
Cataracts Halitosis (bad breathe) Lack of Sex Drive (female) Ulcers
Celiac Disease Headaches Lack of Sex Drive (male)

Surgeries-please indicate all surgeries below:

Chronic Fatigue Syndrome Hemophilia Lactose Intolerance
Cirrhosis (hepatic) Hemmorrhoids Leaky Gut Syndrome
Cold Hands/Feet Herpes Liver Disease
Are you taking any medications either prescribed by a doctor or over the counter?
Medication 1


Medication 2


Medication 3


Medication 4



When is the last time you have taken antibiotics?

Do you notice any side effects from any of the medications?
Do you use tobacco in any way? How do you take it? How much?   Do you use artificial sweeteners such as Equal, Sweet-n-Low, Sucralose?
Do you eat or drink any products with caffeine? If so, how often?   Do you take any vitamins or supplements? If so, how often? Why?
Do you drink alcohol? How often?










Do you experience...            
Acid reflux Constipation Foul smelling gas Rectal itching
Alternating constipation to diarrhea Diarrhea Headaches Ulcers
Bad breath Fatigue Heartburn Undigested food particles in stool
Bloating Gastritis Indigestion Upper abdominal pain
Belching after meals Fat in stool Migraines

Catch colds easily

Fatigue after exercise that persists all day

Become tired and exhausted easily

Crave foods(salt, sugar, chocolate)

Increased anxiety

Easily agitated

Erratic energy levels

Restless sleep


Difficult time getting up in the morning

Achy joints NOT induced by exercise

Energy is worse if I skip a meal

Need coffee and colas to keep going

Difficult time recovering from illness

Decreased sex drive

Unable to handle daily stresses

Mild depression

What amount of energy does your job require you to use:   Do you feel well rested upon rising?
Very little Moderate Great amounts   1-2 /week 3-5 /week 5-7 /week  
How many hours do you work each day?   How often do you wake up in the middle of the night? Is it difficult for you to fall back to sleep?
4 or less 5-8 hours 8+ hours   never/rare 1/wk 1-3x wk 3+/wk
How would you rate the stress level at your work?   How often do you feel the need to take a nap in the afternoon of after lunch?
low medium high   never/rare 1/wk 1-3x wk 3+/wk
What time do you sleep at night?   Do you use a microwave to cook or reheat your food?
8-9 pm 9-10 pm 10-11 pm Night owl yes no    
How many hours do you sleep each night?          
5 or less 6 to 8 8 hour or more          
Is losing weight easy for you? Explain?
Have you tried to gain weight in anyway? Explain?
Is gaining weight easy for you? Explain?
Are you required to be at a certain weight due to medical conditions or because of an athletic event?
Have you tried dieting to lose weight in anyway? Explain?
If you do gain weight, where does your body store the body fat?
Do you exercise regularly? If so, what kind of exercise?
During your exercise sessions is your energy level stable? If not explain.
How often do you exercise?
What sports did you play? (Elementary School , Junior High School, High School, Collegiate)

After exercising, is your energy better or worse?


What sports do you currently play?



Have you ever had silver fillings? Explain?



2011 © Robert Yang