If you are interested in consulting with our Registered Dietitian, and becoming a Sunshine Wellness Nutrition Client, please fill out this detailed questionnaire. All your information is kept confidential and is only used to help assess your nutritional status. Once your information is submitted, a Sunshine Wellness Representative will contact you shortly.
Initial Wellness Questionnaire
Today's Date :	MM/dd/yyyy
Salutation :
First Name :
Last Name :
Email :
Cell Phone :
Home Phone :
Home Street Address :
City :
State :
Zip :
Country :
Where did you hear about us? (Press/hold control button to select multi options) :
If you listed 'Other" above, please specifiy where you heard about us :
List your trusted health practitioner(s). Would you like us to notify them that you are starting a new nutrition program? (If so, please include their address) :
What Sunshine Wellness services are you interested in? (Press/hold control button to select multi options) :
Do You Have Children (under 18) :
Please include any personal information that may assist us. (Examples: married, children, occupation, schedule?) :
Date of Birth :	MM/dd/yyyy
Age :
Height :
What is your current weight & weight history? :
What are your wellness goals that you hope to accomplish through working with Sunshine Wellness Institute? (List them in order of importance - 1, 2, 3, etc.) :
List all your chronic symptoms, medical conditions, and important surgeries. (Rate them in order of significance - 1, 2, 3, etc.) : Examples: Anxiety/Depression, Asthma, Arthritis, Cancer, Chronic Fatigue, Constipation, Eating Disorder, Excess Weight, Headaches, Heartburn, Heart Disease, High Blood Pressure, Loose Bowels, Menopause, PMS, Osteoporosis, Skin Problems, Sleep Problems, Thyroid Imbalance, Yeast Infections, etc. :
What are the limiting factors that may hinder you from reaching these wellness goals? (Examples: lack of time, knowledge, motivation, and/or energy; your mate influences you with bad habits; you have significant health problems, etc. :
Do you take any medications? (If so, please include name of medication/s, what they are used for, how often they are used, and duration of use) :
What do you eat on an average day and what is your meal schedule? 1) Wake Time - Time & Sample 2) Breakfast - Time & Sample 3) Lunch - Time & Sample 4) Dinner - Time & Sample 5) Snacks - Time & Sample 6) Bed Time - Time & Sample :
How often do you eat out every week? (Please include what meals you dine out & favorite type of restaurants) :
Who does the food shopping & cooking in your household? (Please include where you shop and some of your staple meals that you cook) :
Do you take any supplements on a regular basis? (If so, please list your routine) :
Do you drink milk, juice, or water? (If so, please list what kind and how many glasses of each per day) :
Do you consume any of these products? Tobacco, alcohol, diet soda, soda/energy drinks, artificial sweeteners, sugary foods, caffeinated coffee, caffeinated tea. (Please list what kind and how many per day and week) :
Do you exercise on a regular basis? (If so, what types of exercise and how often? If it is easier, you are welcome to write out your exercise schedule) :
Do you consider your life stressful - if so, why? Do you handle stress well? What techniques do you use to manage stress? Do you get 7-8 hours of uninterrupted sleep per night? (If not, explain why) :