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ANALYSIS_Hormones, Diabetes, weight loss
HORMONES, DIABETES & WEIGHT LOSS
Do you have any allergies to foods, medications, chemicals, and/or other environmental substances? If yes, provide details:
What medications are you taking, please list all?
What tests have you had recently?
What job do you have, if any? Please explain if you are in shift work, sedentary or other.
Is there anyone in your family with diabetes? Pleae state if it is type 1 or type 2.
What, if any, other hormonal issues are present in your family?
What 1 or 2 things would you like to change about your diet?
What eating habits need the most improvement?
What foods do you dislike?
What foods do you crave?
What is your usual eating pattern (check all that apply):
varies day to day
varies week vs. weekend
grazer
no pattern/random
skip meals
night-time eating
3 meals/day
3 meals + snacks
Who performs the cooking/shopping?
What grocery store?
What do you drink with meals and in-between meals?
If you snack, what do you usually snack on?
How often do you travel?
Out of 7 days, how often do you dine out for: Breakfast?
Lunch?
Dinner?
What types of restaurants do you typically frequent?
How often do you eat in front of the TV or computer?
What triggers you to eat? (check all that apply)
time of day
hunger
seeing/smelling food
emotions
boredom
other
Do any religious practices or food philosophies affect your diet (ex: Kosher, Vegetarianism)? (describe)
Do you eat more rapidly than others?
Yes
No
Do you eat until feeling uncomfortably full?
Yes
No
Do you eat when you are not feeling physically hungry?
Yes
No
Do you feel guilty after eating?
Yes
No
Do you feel that you cannot control the amounts you are eating?
Yes
No
What diets have you tried to lose weight?
REVIEW OF SYSTEMS (check all that apply):
compulsive over eating
binge eating disorder
anorexia
bulimia
other
*FOR WOMEN : Are you currently pregnant?
Yes
No
*FOR WOMEN : Are you actively trying to conceive?
Yes
No
*FOR WOMEN : Menstruation details. Cycle length, period length, regular or irregular, clotting and size, PMS, cravings, heavy or light, dark or light coloured bleeds. OCP use.
*FOR MEN : Erectile insufficiency, prostate enlargement
ENDOCRINE
Diabetes Mellitus
Thyroid disease
Elevated cholesterol
Elevated triglycerides
Gout
Other
Describe if you choose other
Age
D.O.B
Phone Number
Email
Name
Occupation
Normal work hours
SUBMIT