This heath assessment is designed to identify and analyze the 11 organ systems of the body while determining areas where your patients may require nutritional support. The analysis also considers your patient’s medical history, diet and lifestyle patterns, genetic risk factors and more. Please have your patients fill out this form and send it back to us either by fax or email, or they can submit it online. For a more comprehensive analysis, you may opt to send us your patient’s recent laboratory results along with the completed assessment. Our Nutrition team will review the assessment and lab results and provide supplement recommendations within 24-48 hours.
HEALTH IMPROVEMENT ASSESSMENT
Present medical condition: Please list any known medical concerns that you have at present.
Date(s) of onset :
Past surgery: Please list in chronological order any surgeries (hospital and out-patient) that you have had.
Type of surgery/surgeries:
Please complete the following information, if your parents' medical history is known.
On average, how many servings of fruits and vegetables do you consume per day?
On average, how many servings of dairy products do you consume per day?
On average, how many servings of fish (i.e. salmon, tuna, mackerel or sardines) do you consume per week?
Do you smoke or are you exposed to secondhand smoke or chemical pollutants on a regular basis?
What’s your level of physical, mental or emotional stress?
How many times a week do you exercise for at least 30 minutes?
Do you participate in strenuous physical activity (i.e. weight lifting, sports etc.) on a regular basis?
Are you pregnant or breastfeeding?