Trudy Scott

Full Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

E-mail

Birth Date

MonthDayYear

Current Weight

Ideal Weight

Height

Blood Pressure

Gender

Age

Marital status

Able to work full-time?

Profession

Past profession(s)

Do you have a medical diagnosis? If yes, what?

Referred by or How did you find me?

Please list your top 5 health goals.

Your Mood/Energy/Sleep/Digestion – please rate how bad and add notes if needed.

Depressed?

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1 is Best, 10 is Worst

...additional notes on "Depressed?"

Suicidal now/past/thoughts?

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...additional notes on "Suicidal now/past/thoughts?"

Mood swings? Daily? Monthly? Other?

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...additional notes on "Mood swings? Daily? Monthly? Other?"

Anxiety?

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...additional notes on "Anxiety?"

Panic attacks?

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...additional notes on "Panic attacks?"

Inability to socialize?

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...additional notes on "Inability to socialize?"

Low energy? Focus?

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...additional notes on "Low energy? Focus?"

Poor sleep? Number of hrs?

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...additional notes on "Poor sleep? Number of hrs?"

Poor digestion?

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...additional notes on "Poor digestion?"

Stressed out in general?

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...additional notes on "Stressed out in general?"

Obsessive behaviors or thoughts?

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...additional notes on "Obsessive behaviors or thoughts?"

Hormonal issues? PMS? Menopause?

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...additional notes on "Hormonal issues? PMS? Menopause?"

Thyroid issues?

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...additional notes on "Thyroid issues?"

Other mood issues?

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...additional notes on "Other mood issues?"

Depressed?

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...additional notes on "Depressed?"

Your Work Stress – please rate how bad and add notes if needed.

Work overwhelm?

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...additional notes on "Work overwhelm?"

Work worry & fear about decisions?

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...additional notes on "Work worry & fear about decisions?"

Procrastination?

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...additional notes on "Procrastination?"

Negative self-talk and/or inner dialogue? Critic on the shoulder?

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...additional notes on "Negative self-talk and/or inner dialogue? Critic on the shoulder?"

Perfectionist? No one can do it as well as me?

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...additional notes on "Perfectionist? No one can do it as well as me?"

“I am a fraud”/imposter syndrome?

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...additional notes on "“I am a fraud”/imposter syndrome?"

Do you consider yourself an introvert?

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Workaholic? Working long hours? Hours per week?

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...additional notes on "Workaholic? Working long hours? Hours per week?"

Use coffee and/or sugar to keep going?

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...additional notes on "Use coffee and/or sugar to keep going?"

Emotional and crying spells?

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...additional notes on "Emotional and crying spells?"

Feel better when exercising?

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...additional notes on "Feel better when exercising?"

Your Food/Eating/Drugs/Alcohol – please rate how bad and add notes if needed.

Cravings? What do you crave? When?

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...additional notes on "Cravings? What do you crave? When?"

Calorie restriction/calorie counting/dieting?

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...additional notes on "Calorie restriction/calorie counting/dieting?"

Binging? Purging? How often? For how long?

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...additional notes on "Binging? Purging? How often? For how long?"

Use of alcohol/drugs? Addiction? What? How much? And how often?

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...additional notes on "Use of alcohol/drugs? Addiction? What? How much? And how often?"

Eat sugar or drink alcohol to calm down?

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...additional notes on "Eat sugar or drink alcohol to calm down?"

Vegetarian? For how long? Would you consider adding any animal products into your diet?

Anything else I should know about your eating habits?

Your Medications now (name, dose, reason taking)

Your Medications in the recent past (name, dose, reason taking, response/reaction)

Your Supplements now (name, dose, reason taking)

Have you used targeted individual amino acids (glutamine, GABA, tryptophan, 5-HTP, DPA or tyrosine) and had good results with anxiety mood, cravings, fatigue?

Have you tried any other supplements and/or other natural methods and had good results with anxiety mood, cravings, fatigue?

Are you in therapy/12-step etc now (or in the past)? Please elaborate.

Your family – mood, addictions, eating disorders and other conditions

Depressed

Anxious

Food Addiction/ Eating disorder

Alcohol/Drug Abuse

Thyroid problems

Heart disease/stroke

Cancer

Fertility/miscarriage

Other health conditions in family members

Anything else I should know about?

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Today's Date

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Initial Assessment