at Fertile Ground Wellness Center 1091 S Gaylord Street Denver, CO 80209

at Fertile Ground Wellness Center
1091 S Gaylord Street
Denver, CO 80209
www.janeyappleseednutrition.com
Welcome! I’m excited to begin our work together!
PLEASE BRING WITH YOU TO OUR FIRST APPOINTMENT*:
1. Completed Health History form + MAF form
2. Bottles of dietary supplements you are currently taking (or considering taking) which may
include any of the following examples: multivitamin, fish oil supplement, protein powders, dietary
fiber supplements, green powders, antioxidant formulas, etc. The bottles are required so that we
can identify the specific amounts and forms of the various nutrients.
3. Pertinent Blood Work Results from current and past doctor visits.
* For remote consultations: please include a list of dietary supplements you are taking (including brand
and dosage) and include this when you fax or scan/email all completed forms to me 24 hours BEFORE
our appointment.
As it is always helpful for us to have ample time to review this pertinent information,
we request that you send us your Health History & MAF Questionnaire at least one day
prior to your scheduled appointment. If accessible, you can send your paperwork to us
by scanning and emailing it to [email protected] or faxing to
720.836.4174. All remote consultations MUST fax or scan/email completed forms at
least 12 hours before your scheduled appointment.
“One cannot think well, love well, sleep well, if one has not dined well.”
-- Virginia Woolf
Sarah Jane sandy, CNT
Janey Appleseed nutrition
Janey Appleseed Office Policies
SCHEDULING APPOINTMENTS: To schedule or change an appointment, please call:
303.248.3481 (office), 303.656.3847 (cell) or email [email protected]
PAYMENT FOR SERVICES: Payment in full is required at time of service unless other
arrangements have been made ahead of time. We accept cash, check and credit card. Please make
checks payable to: Sarah Jane Sandy, CNT.
CANCELLATIONS: We understand unforeseen events arise that may prevent you from making
your scheduled appointment. However, missing an appointment is a loss to everyone. Kindly provide
at least 24-hours notice if you need to cancel an appointment, or payment in full will be required for
the time slot that was reserved for you. We will be happy to reschedule you.
INSURANCE COVERAGE: Unfortunately, most insurance companies do not cover nutrition
appointments, even when they are doctor-prescribed. Hopefully, this will change in the future. It is
the patient’s responsibility to provide payment in full at time of service and then request
reimbursement from the insurance company.
CONFIDENTIALITY: All information disclosed within sessions is confidential as outlined in the
HIPAA notice of Privacy Practices. Additional copies can be made available during your office visit.
OFFICE HOURS: Office hours are Monday and Wednesday. Remote Consultations are always
available (either by telephone or Skype). Please call to reserve an appointment time.
____________________________________________
Signature _________________
Date
Please let us know if you have any questions.
Sarah Jane sandy, CNT
Janey Appleseed nutrition
Pricing Information
Initial Consultation: $150 (75 minutes)
Follow-Up Sessions: $95 (45-60 minutes); $60 (30 minutes)
Packages
Initial Consultation + 4 Follow-Up Sessions: $477 (regularly $530)
5 Follow-Up Sessions: $427 (regularly $475)
8 Follow-Up Sessions: $646 (regularly $760)
Grocery Store Walkabout + Cooking Class: $95/hour (2-3 hours)
Private Yoga Session: $65/hour
3 sessions: $180
5 sessions: $280
Programs
Increase Fertility with Nutrition: $560 (regularly $625)
You want to have a baby. Perhaps you’ve been trying for months, or even years. Maybe you’ve
exhausted all the traditional medical solutions with no luck. Maybe you are looking for alternatives.
Or, maybe you can’t afford the high price of IVF. Whether you have an undiagnosed mystery, or a
specific health condition, the most important thing you can do to increase fertility and finally
become pregnant, despite the odds, is to choose foods that create the right environment for a
healthy baby. Is there a fertility diet? We do know that women who are closer to their healthy body
weight have better odds of conception than women who are over or under their ideal weight. In
addition, there is evidence that conditions like PCOS, endometriosis, and yeast overgrowth, which
may negatively impact fertility, can be treated with dietary modification. Unique to Janey Appleseed
Nutrition is a nutritional program formulated to nourish reproductive health, increase fertility, and
improve a couple’s opportunity for conception and a healthy pregnancy. Sarah is specifically trained
in how foods and nutrients affect our reproductive systems and has notable success designing
dietary programs to strengthen fertility vibrance and help couples get pregnant. This program will
guide you in dietary and lifestyle changes that will strengthen both partners reproductive health and
improve chances for a successful, healthy pregnancy. Because the egg and sperm each take
approximately 90 days to develop, this package takes you through the entire 3 months in order to
create the most ideal environment for the sperm and egg to mature in.
Includes:
• Initial Consultation, 75 min
•
Complete Hormone Testing Lab Review (Complete Hormones panel billed separately)
•
3 follow-up visits, 60 min each (spaced 1 week apart)
•
2 follow-up visits, 60 min each (spaced 2 weeks & 4 weeks apart)
Recovery and Preparation: $560 (regularly $625)
Heal your body and prepare for pregnancy with our ART (Assisted Reproductive Technology)
recovery and preparation program. This healing nutrition program is specially designed for women
who have:
• Recently failed an ART cycle (IUI, IVF, or other)
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Janey Appleseed nutrition
•
Experienced a miscarriage
•
Received a difficult diagnosis from your fertility doctor
•
Are taking a break from medical fertility treatment
It is important to acknowledge that medical fertility treatment can take a toll on more than our minds
and emotions. Repeated exposure to the stress, hormone medications and medical procedures can
impact our body’s ability to heal itself. There is also increasing evidence that nutrition-related
conditions such as chronic inflammation, poor gut health, increased body weight, and poor blood
sugar balance can negatively impact our ability to conceive. These conditions are exacerbated by
stress, as well as the rigors of treatment.
The ART Recovery and Preparation program combines an anti-inflammatory/hypoallergenic way of
eating with targeted nutrition supplements that directly support the liver and promote clearance of
metabolic toxins, hormone medications, and other fertility drugs. The program also restores optimal
gut function, because studies are showing that women who have undergone multiple IVFs are at
higher risk of bacterial vaginosis. This condition is linked to both miscarriage and failed IVF.
At Janey Appleseed Nutrition, we believe that a deeply healing diet supported with adequate
nutrients through supplementation can go a long way in preparing your body to continue on the
journey towards motherhood. Whether your next steps are another ART cycle, or you plan to take
some time to try naturally, it is important to honor and address the impact that treatment,
disappointment or losses can have on your next fertility cycle.
Includes:
• Initial Consultation, 75 min
•
3 follow-up visits, 60 min each (spaced 1 week apart)
•
2 follow-up visits, 60 min each (spaced 2 weeks & 4 weeks apart)
Conscious Preconception Care: $560 (regularly $625)
Are you interested in consciously preparing your body BEFORE trying to conceive? The importance
of preconception care and readying the body before attempting to conceive is largely lost in our
modern world. It is now widely established that the nutritional environment of a mother’s womb
affects her baby’s health not only at birth and during early infancy, but for the rest of his or her life.
But what is less well known is that a mother and father’s diet and lifestyle choices in the months and
even years leading up to conception is equally important! This is why traditional cultures have sacred
fertility foods they feed to mothers-to-be and even fathers-to-be. These include nutrient dense foods
that are hard to find on modern day dinner plates, things like fish eggs, liver, bone marrow, egg yolks
and other animal fats. For example, the Masai tribe in Africa only allowed couples to marry and
become pregnant after spending several months drinking milk in the wet season when the grass is
lush and the nutrient content of the milk is especially high.
Unfortunately this traditional wisdom has been largely lost in the modern world. A mother’s (and
father’s) diet prior to conception and during pregnancy may be one of the most important factors in
determining the lifelong health of her baby. A large problem is that many women are
(understandably) confused about what constitutes proper nutrition during the pre-conception and
pregnancy period. There’s so much contradictory information out there, and it can be difficult for the
layperson to know what to believe and who to trust. In this program you will discover the essential
steps you should take BEFORE conception in order to promote fertility, a successful, healthy
pregnancy, and lifelong health for you and your baby. It is wise to begin conscious preconception
care at least 4 months before attempting to conceive. Because the egg and sperm each take
Sarah Jane sandy, CNT
Janey Appleseed nutrition
approximately 90 days to develop and mature, this program takes you through an entire 3 months in
order to create a fully fertile body, mind, and spirit.
Includes:
• Initial Consultation, 75 min
•
Complete Hormone Testing Lab Review (Complete Hormones panel billed separately)
•
3 follow-up visits, 60 min each (spaced 1 week apart)
•
2 follow-up visits, 60 min each (spaced 2 weeks & 4 weeks apart)
Eating for a Healthy Pregnancy: $560 (regularly $625)
What can I do for morning sickness? Does it matter what brand of prenatal vitamin I take? What if
I’m not that hungry, will my baby still get what he needs? I know protein is important, but how much
do I need to be eating every day? Discover the answers to these, and many other, questions in this
informative and eye opening program. You will learn exactly what to eat for a healthy pregnancy,
what vitamins and supplements are important to include (and why quality matters!), what specifics to
focus on during each trimester, and many other critical factors to ensure a healthy, happy pregnancy
and a well nourished baby.
Recent research suggests the a mother’s nutritional status during, AND before, pregnancy is one of
the most powerful influences on a child’s lifelong health. In fact, some researchers now believe the 9
months of pregnancy are the most consequential period of our lives, permanently influencing the
wiring of the brain and the function of organs like the heart, liver and pancreas. They also suggest
that the conditions we encounter in-utero shape everything from our susceptibility to disease, to our
appetite and metabolism, to our intelligence and temperament.
Includes:
• Initial Consultation, 75 min
•
1 follow-up visit during first trimester, 60 min
•
2 follow-up visits during second trimester, 60 min each
•
2 follow-up visits during third trimester, 60 min each
Begin Again!: $560 (regularly $625)
Do you need to lose weight? Are you tired and fatigued? Do you have food allergies but not sure
how to manage them? Is your digestive system out of whack? Are your hormones imbalanced? Feel
like you’ve fallen off track? In this program we will cover everything you need to know to begin to
nourish your body and achieve your health goals.
Includes:
• Initial Consultation, 75 min
•
Grocery Store Walkabout, 60 min (includes shopping list & recipes)
•
2 follow-up visits, 60 min each
•
4 follow-up visits, 30 min each
Menu Planning: $55/hour
1-week menu plans take approximately 2-3 hours to create & include shopping lists and recipes. Grocery Store Walkabout: $95/hour*
Sarah Jane sandy, CNT
Janey Appleseed nutrition
A custom-guided tour of the health food store of your choice*. You will learn about the benefits of
various foods, which brands are best to choose, what ingredients to avoid, how to read and
decipher labels, how to avoid food allergens, and other essential details as you shop to maintain
wellness and nourishment.
*($.50 per mile, roundtrip applied for stores located beyond 80209 zip code)
Cooking Class (Individual or Partners): $95/hour (2 hours)
Hands-on cooking classes that introduce a variety of foods and simple preparation techniques,
making healthy eating enjoyable. Includes recipes and shopping lists. Lab Testing
Comprehensive Wellness Profile, blood
The comprehensive blood panel is the single most efficient, effective and affordable tool for quickly
evaluating your health. It screens for a wide range of conditions, including several types of anemia;
gut, viral and bacterial infections; insulin resistance and hypoglycemia; liver and kidney issues; and
thyroid and adrenal problems. It reveals important information about the types, amount and
distribution of the various types of fats (lipids) in the bloodstream. It offers important clues for how to
structure and focus your treatment to get the best results. And it provides a baseline of biomarkers
that can be used to objectively track the progress of your treatment over time.
Also available: Comprehensive Wellness Profile with full thyroid assessment including
thyroid antibodies, blood
Complete Hormones, urine
The most comprehensive urinary hormone metabolism evaluation designed to assist in the
prevention and treatment of hormone-related symptoms and conditions. This provides clues about
menstrual irregularities, infertility, menopause, fatigue, breast cancer, and osteoporosis.
The Benefits of Urine Hormone Testing include:
• Simple, at-home collection options offer the advantage of a time average, effectively
integrating spikes that may occur in these hormones over time
•
Measures the free, bio-available fraction of hormones, meaning theportion of hormones that
are active in the body
•
Measures the metabolites of important steroid hormones and provides a robust analysis of
hormonal excess or deficiency, and helps to assess the adequacy and safety of hormone
replacement therapy (HRT)
•
Measures the Anabolic/Catabolic Balance (ACB): the ability for “growth and
healing” (anabolic) versus the state of “wear and tear” (catabolic)
•
Measures Methylation Capacity: methylation is required for effectively eliminating
carcinogenic (cancer causing) hormone metabolites, and for activating protective hormones
against cancer
Complete Hormones is ideal for the prevention and treatment of the following symptoms and
conditions: anxiety, depression, fatigue, poor memory, loss of libido, menopausal symptoms,
premenstrual symptoms, PCOS, osteoporosis, uterine fibroids, muscle weakness and atrophy,
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Janey Appleseed nutrition
hypoglycemia and diabetes, cardiovascular disease, headaches and migraines; breast, uterine, and
ovarian cancer.
Adrenal Stress Index, saliva
The Adrenal Stress Index is a test of adrenal function and can determine the functioning of our
body’s stress gland. Four saliva samples are used in the ASI™ for the following ten tests:
• 4 x Cortisol: Helps evaluate stress response
•
2 x Insulin: Helps investigate blood sugar control
•
DHEA: Helps determine stress adaptation
•
Secretory IgA: Helps evaluate toll on immunity
•
17-OH Progesterone: Helps determine adrenal reserve
•
Gluten Antibodies: Helps identify grain intolerance
Do you need the ASI™ Test? The ASI™ is mostly ordered for individuals that suffer from:
• Chronic stress and related health problems
•
Lack of vitality and energy
•
Muscle and joint pain
•
Hypoglycemia
•
Migraine headaches
•
Osteoporosis
•
Sleep disturbances
•
Poor memory
•
Alcohol intolerance
•
Stress maladaptation
•
Low sex drive
•
Low body temperature
•
Anxiety/Panic Attacks
Comprehensive Metabolic Profile
Test, Don’t Guess! The Comprehensive Metabolic Profile assesses your nutritional and metabolic
health with no blood draw required. Many chronic health problems can be difficult to diagnose,
especially when they involve nonspecific symptoms such as fatigue, foggy thinking, gastrointestinal
upset, joint aches, sleep disturbances and more. Standard medical testing is designed to
identify disease states. Metabolic testing does not diagnose disease, it helps to give insight into the
causes of disease. The CMP will also help assess specific metabolic dysfunction that is used to
customize a nutritional program unique to your body to help you manage those areas in need of
support.
Sarah Jane sandy, CNT
Janey Appleseed nutrition
ELECTRONIC PAYMENT AUTHORIZATION
Please indicate the form of payment you wish to use for any services rendered through this practice.
The following forms of payment are accepted: Visa, MasterCard and Discover. Service fees will be
deducted from the designated account at the time services are rendered.
Client Information:
Client Name: ________________________________________ Date of Birth: __________________
Address: __________________________ City__________________ State: _______ Zip: ________ Home
Number: __________________________ Mobile Number: __________________________
Cardholder Information:
Please indicate the name and address associated with the credit or debit card you wish to use.
Name: ____________________________________________________________________________
Address: __________________________ City__________________ State: _______ Zip: ________ Email:
_________________________________________________________________________
I authorize any service fees to be deducted from the credit or debit card ending in _________
(provide the last four digits of the card).
______________________________________
Cardholder Signature
Date
____________________
------------------------------------------------------------------------------------------------------------------Credit/Debit Card Information:
Please provide your payment information below. The debit or credit card information you provide on
this form will be destroyed once your first payment has been made.
Card Type (circle one):
Visa
MasterCard
Discover
Card Number: ____________________________________________ Expiration Date: _______________
Verification Code:________ (located on the back of the credit card, the last three digits to the right of
the card number.)
Sarah Jane sandy, CNT
Janey Appleseed nutrition
Health History
Date_________________
Name_______________________________________________Age________Date of Birth________________________________
Address____________________________________________________________________________________________________
Home Phone_____________________Cell/Work Phone________________________Email_______________________________
Relationship Status____________Children?_____Occupation______________________Hours per week you work_________
Emergency Contact_____________________________Phone_________________________Cell___________________________
Are you currently under a doctor’s care or any other health professional? Y N Please provide name and reason:
____________________________________________________________________________________________________________
How did you hear about us? (doctor, nurse, flyer, website, friend, other)____________________________________________
What is your primary reason(s) for seeking nutrition counseling? Please describe current condition.
What do you feel are your biggest nutritional challenges and difficulties?
Do you have any chronic health problems or other diagnoses, (such as anemia, high cholesterol, high blood pressure,
hypoglycemia, gastrointestinal problem, etc.)? Please include date diagnosed and all current and past treatment.
Please list all vitamins, herbs or medications that you are currently taking or have taken in the past 2 months:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Please list all vitamins, herbs or medications that your spouse is taking or has taken in the past 2 months:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Do you experience chronic pain anywhere in your body? Y N Where?________________________________________
On a scale of 1-10, how would you rate your pain?________
How would you describe your overall general health now?
How has it been most of your life?
Poor
Fair
Good
Poor
Fair
Good
Excellent
Excellent
Do you sleep well?________ Do you wake up at night?________ Do you feel refreshed when you wake up?__________
Do you use medication for sleep?
Y
N If so, what kind and how often? _______________________________________
Do you have good energy levels?
Y
N
Inconsistent
Current Height:________ Current Weight:________ Weight six months ago:________ One year ago:________
Do you consider yourself:
Underweight
Sarah Jane sandy, CNT
Overweight
Just Right
Janey Appleseed nutrition
Please circle:
I have / have not previously used diet or exercise to lose or gain weight.
I have / have not previously used medications or supplements to lose or gain weight.
Do you diet frequently?________ Are you currently on a diet?________ If yes, please describe:_________________________
General Medical History
Please indicate if you currently have or have had in the past year any of the following symptoms or diagnoses with a
letter “S” for self. Also, please mark any illnesses that you believe one or more of your parents/grandparents/siblings
have had with an “F” for family:
____Acne breakouts
____Facial hair growth
____Leg/muscle cramps
____Thyroid disease
____Alcoholic
____Fainting/dizzy spells
____Less than 1 bowel
____Ulcerative Colitis
____Allergies
____Feel hot often
movement per day
____Unexplained Weight
____Anemia
____Feel cold often
____Liver Disease
Gain
____Antibiotic use
____Fibroids
____Low Blood Pressure
____Yeast Infections
(extended)
____Gastritis
____Low Cholesterol
(chronic)
____Anxiety
____Hair loss/thinning
____Low libido
____Autoimmune disease
____Headaches
____Lupus
____Bloating/gas
____Heartburn/reflux
____Menstrual clotting
____Candida Albicans
____Hemorrhoids
____Menstrual cramps
____Celiac disease
____Herpes
____Mercury Amalgams
____Chron’s Disease
____High Cholesterol
____Migraines
____Colds/flu
____High Blood Pressure
____Multiple Sclerosis
____Constipation
____Hot Flashes
____Nausea
____Depression
____Hypoglycemic
____Nervous breakdown
____Diarrhea
____Hypothyroid
____Nervousness
____Diverticulosis
____Hyperthyroid
____Numbness
____Drug Addictions
____Insomnia
____Polycystic Ovarian
____Dry skin
____Irregular menses
Syndrome
____Dry hair
____Irritable Bowel
____Rheumatoid arthritis
____Eczema
Syndrome
____Sciatica
____Endometriosis
____Irritable/depressed
____Skin ulcers
____Excessive fatigue
during menses
____STD
REPRODUCTIVE HISTORY
Women:
Regular menses cycle? Yes ___ No ___; # of days between periods?___; Length of period?______; Clots?______
Flow is Heavy ___ Medium ___ Light ____; Pain or Cramping? Yes ___ No ___; Abnormal Discharge? Yes___ No ___
Date of last period______________ PMS symptoms:_____________________________________________________________
If you use a contraceptive, what type?________________For how long?_________Symptoms:_________________________
Number of pregnancies:________
Miscarriages:________
C-sections:________
Are you trying to conceive?______ If yes, how long have you been trying to conceive?_______________________________
Have you sought Assisted Reproductive Technology previously?________ If yes, what have you done & results?________
___________________________________________________________________________________________________________
Has your partner been tested for any fertility-related problems?_________If yes, what were the results?________________
____________________________________________________________________________________________________________
Menopause?__________ Age at menopause: _______ Symptoms: _________________________________________________
Please rate your current sexual libido on a scale of 1-10 (10 being the highest):__________
Sarah Jane sandy, CNT
Janey Appleseed nutrition
NUTRITION INFORMATION
On a scale of 1-10 (10 being extremely healthful), how do you rate your diet?_____ / 10
Please describe any current dietary restrictions that you may have:________________________________________________
____________________________________________________________________________________________________________
Do you have food allergies?_________If so, please describe:______________________________________________________
Please describe what you think are your “worst” food habits:_____________________________________________________
What foods do you crave?____________________________________________________________________________________
What foods do you avoid? Why?______________________________________________________________________________
Do you snack during the day?________Describe: _______________________________________________________________
Please describe what a “typical” day of food consists of for you (i.e., breakfast = cereal with milk and coffee, lunch =
salad with low-fat dressing and half turkey sandwich, dinner = spaghetti with meatballs, garlic bread and wine, snack =
almonds and an apple):_______________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
How many glasses of water do you drink per day?__________ What is your drinking water source? Tap Bottled
Filtered Reverse Osmosis
Distilled Well
Food Frequency: How often do you eat the following foods? Place a check mark in the appropriate box.
FOODS
NEVER
<1x/MONTH
<1x/WEEK
2-4x/WEEK
DAILY
Fresh vegetables
Fresh fruit
Milk
Cheese
Yogurt
Ice cream
Soy/soy foods
Nuts & seeds
Nut butters (i.e. peanut
butter, almond butter)
Beans/legumes (i.e.
hummus)
Whole grains (i.e.
brown rice, quinoa,
oatmeal)
Sarah Jane sandy, CNT
Janey Appleseed nutrition
FOODS
NEVER
<1x/MONTH
<1x/WEEK
2-4x/WEEK
DAILY
Bread
Pasta
Crackers/Chips
Boxed cereal
Fish
Red meat
Chicken/turkey
Pork/ham/bacon
Eggs
Butter
Margarine
Canola Oil (or other
vegetable oil)
Olive oil
Fried foods
Sweets (dessert,
candy, cookies,
chocolate)
Artificial Sweetener
(i.e. Splenda, Equal,
chewing gum)
Gatorade/ other
energy drinks
Juice
Alcohol
Caffeine
Soda/diet soda
Any foods that are not listed that are consumed regularly________________________________________________________
Any beverages that are not listed that are consumed regularly____________________________________________________
What percentage of your food do you buy organic?______% What food items do you choose to buy organic?__________
____________________________________________________________________________________________________________
What percentage of your food is freshly prepared?______%
What percentage of the food that you prepare comes frozen, canned, in a box or pre-made?______%
Sarah Jane sandy, CNT
Janey Appleseed nutrition
Meal Planning:
Who plans your meals?___________ Who cooks?___________ Who shops?___________ Do you like to cook?___________
If no, would you be willing to learn some basic cooking techniques?___________
Where do you do most of your grocery shopping?______________________________________________________________
Dining Habits:
How many times per week do you eat the following at home? away from home?
Breakfast____/____
Lunch____/____
Dinner____/____ How often do you eat:
At fast food restaurants?__________
At casual dining restaurants?__________
At business meetings?__________
At “fine dining” restaurants?__________
“On the run” (rushed, in the car, standing in the kitchen, etc.) __________
In front of the t.v.?__________
Are you conscious of what and how much you put in your mouth?
Y
N
Do you consider yourself a fast-eater or a slow-eater (circle one)? Do you chew your food thoroughly?_________
Are you often ravenous before meals?
Y
N
Are you often overly full at the end of each meal?
Y
N
Sugar Consumption:
How often do you consume white/refined sugar or white/refined sugar products (includes candy, chocolate, cookies,
pastries, dessert, honey, agave, maple syrup, etc)?
Often___ Eat daily___ Binge___ Moderate___ Eat several times weekly___ Rarely___ None___
How does eating sugar make you feel, both physically and emotionally/mentally?___________________________________
Do you use other sweeteners besides sugar? If so, which ones?__________________________________________________
EXERCISE
Do you exercise? Y N If so, how often? Daily Every other day Twice per week Once per week Rarely/Never
What type of exercise do you do?_____________________________________________________________________________
How do you feel about your amount of exercise?
Less than I need
More than I need
Just Right
EMOTIONAL STATE
Which of these apply to you?
Happy Sad Depressed Lonely
Isolated
Anxious
Fearful
Angry
Content
Joyful
Judgmental
Irritated
On a scale of 0 (no stress) to 10 (FREAKING OUT), how do you rate your overall daily stress level?__________
How would you rate your level of happiness in life (scale of 1 – 10, 10 being the highest): ________
How would you rate your level of happiness in your job (scale of 1 – 10, 10 being the highest):________
Please list the major stressors in your life:_______________________________________________________________________
____________________________________________________________________________________________________________
Sarah Jane sandy, CNT
Janey Appleseed nutrition
What activities do you engage in to counterbalance stress in your life?_____________________________________________
____________________________________________________________________________________________________________
If you could change one thing in your life right now, what would it be?_____________________________________________
___________________________________________________________________________________________________________
Do you ever eat when you are sad, worried, or upset? (If yes, please describe.)______________________________________
____________________________________________________________________________________________________________
What do you do to help you relax, fall asleep or “wind down” at the end of a stressful day?___________________________
____________________________________________________________________________________________________________
Please provide any other insights and/or information that you feel might be helpful in your health maintenance:_________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Symptom Questionnaire
(Adapted from Julia Ross’s book, “The Diet Cure”)
This questionnaire is a quick way to assess many potential root causes of clinical conditions. We use this
questionnaire as a springboard to develop a personalized nutrition program and, upon follow-up, to assess
improvement.
Hormones (women only) ________Total Score
4
Premenstrual mood swings
4
Premenstrual or menopausal food cravings
4
Irregular periods or migraines
3
Experienced miscarriage, abortion, or infertility
4
Use(d) birth control pills or hormone medication
3
Uncomfortable periods - cramps, lengthy or heavy bleeding, sore breasts
4
Peri- or postmenopausal discomfort (hot flashes, weight gain, sweats, insomnia, mental dullness)
3
Skin eruptions with period
If your score is over 6, your hormones may be out of balance and you may benefit from salivary hormone
testing to determine baseline hormone levels. Well-balanced hormones regulate everything from reproduction
to emotions, general health, and well-being.
Blood Sugar and Stress
________Total Score
4
Crave a lift from sweets or alcohol, but experience a drop in mood afterwards
4
Family history of diabetes, hypoglycemia or alcoholism
4
Fatigue after meals
3
Nervous, jittery, irritable, headachy or worse, on and off during the day. Calmer after meals.
3
Frequent infections, allergies or asthma, especially when the weather changes
3
Mental confusion, decreased memory, hard to focus or get organized
4
Frequent thirst
3
Night sweats (not due to menopause)
5
Light-headed, especially upon standing up
4
Crave salty foods or licorice
4
Often feel stressed, overwhelmed and exhausted
4
Dark circles under eyes or eyes sensitive to bright light
4
More awake at night
If your score is over 12, it’s important that you work on balancing blood sugar and controlling your stress
levels.
Sarah Jane sandy, CNT
Janey Appleseed nutrition
Thyroid Function ________Total Score
4
Low energy
4
Easily chilled (especially hands and feet)
4
Other family members have thyroid problems
4
Gain weight easily, without overeating; hard to lose excess weight
3
Have to force yourself to do even moderate exercise
4
Find it hard to get going in the morning
3
High cholesterol
3
Low blood pressure
4
Weight gain began near the start of menses, pregnancy, menopause or after traumatic event
3
Chronic headaches
3
Loss of outer third portion of eyebrows
3
Depression, loss of vitality
3
Use food, caffeine, tobacco and/or other stimulants to get going
If your score is over 15, you may need to get your thyroid checked. There are many ways nutritionally to
support your thyroid, for more energy, naturally.
Food Allergies
________Total Score
3
Crave milk, ice cream, yogurt, or cheese or doughy foods and eat them frequently
3
Experience bloating after meals
4
Gas, frequent belching
3
Digestive discomfort of any kind
3
Chronic constipation and/or diarrhea
4
Respiratory problems, such as asthma, postnasal drip, congestion
3
Low energy or drowsiness, especially after meals
4
Allergic to milk products or other common foods
3
Under-eat or often prefer beverages to solid foods
3
Avoid food or throw up food because bloating after eating makes you feel fat or tired
4
Can’t gain weight
3
Hyperactivity or depression
3
Severe headaches or migraine
4
Food allergies in the family
If your score is over 12, you may be craving foods you are allergic to. Elimination diets can pinpoint the
offending foods, and elimination of them usually results in weight loss and increased energy.
Antinutrient Load ________Total Score
1
Drink tap water majority of the time
1
More than half the food you eat is not organic
1
Spend an hour or more a day in traffic
1
Live in a city
1
Smoke, or live or work with smokers
1
Eat fried foods often
1
Eat nonorganic meat or fish or large fish like tuna or swordfish
1
Take more than twenty painkillers in a year
1
Take, on average, one course of antibiotics each year
1
Most of the food you eat or drink is in contact with soft plastic or cling wrap
1
Consume an alcoholic drink on most days
The ideal score is 0. A score of 5 or more means you are likely to be taking in a significant quantity of
antinutrients. Any yes answer highlights areas in your diet and lifestyle that warrant attention.
Yeast
4
3
2
4
4
Often bloated; abdominal extension
Foggy-headed
Depressed
Recurrent yeast infections
Used antibiotics extensively (any point in life)
Sarah Jane sandy, CNT
________Total Score
Janey Appleseed nutrition
4
Used cortisone or birth control pills for more than one year
4
Have chronic fungus on nails or skin; athlete’s foot
3
Recurring sinus or ear infections as an adult or child
3
Achy muscles and joints
4
Rashes
3
Stool unusual in color, shape or consistency
If your score is over 12, you most likely have yeast overgrowth which can be addressed through dietary
changes and nutritional therapies.
Low Calorie Dieting ________Total Score
4
Increased cravings for and focus on food, overeating
4
Regain weight after dieting, more than was lost
3
Increased moodiness, irritability, anxiety or depression
3
Less energy and endurance
3
Usually eat less than 2,100 calories/day
3
Skip meals, especially breakfast
3
Eat mostly low-fat carbs like bagels and pasta
2
Constantly think about weight
2
Use aspartame daily
2
Take Prozac or similar serotonin-boosting drugs
2
Have become vegetarian
3
Decreased self-esteem
4
Have become bulimic or anorexic
If your score is over 12, your body may not be burning calories as fast as it could and should, due to low
calorie intake. You may also be deficient in critical nutrients. Through counseling, you will learn why it’s
important NOT to deprive yourself of food.
Sarah Jane sandy, CNT
Janey Appleseed nutrition
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