Surveys should never ask for any sensitive or secure data. Do not provide passwords, credit card numbers, identification numbers, or other sensitive information. Report Abuse.
Skip survey header

BuzzNutrition New Client Intake

BuzzNutrition New Client: Nutrition

Please provide a fake name, so that your data remains anonymous.
14. Medication history: Have you ever taken antibiotics? Please check all that apply.
15. Medication history: Have you ever been prescribed cortical steroids, like hydrocortisone?
19. Do you smoke cigarettes?
21. How would you describe your diet? (Check all that apply.)
22. Are you allergic to any foods? (do they cause hives, difficulty breathing, anaphylactic shock)
23. Do you have an intolerance or sensitivity to any foods? (Cause a wider array of symptoms & are not life-threatening like an allergy.)
24. How many times per day to you eat?
25. What happens if you skip a meal?
26. On an average day, how do you feel before you eat?
27. On an average day, how do you feel after you eat?
33. Please choose the types of fats you eat most often (check all that apply):
34. How's your poop?!
35. How would you describe your energy level?
36. Please describe your stress level.
37. How many times per day to you laugh?
38. How often do you have fun?
39. Do you have any problems sleeping?
40. Once you're asleep, do you have problems staying asleep?
41. When are you asleep? (Ex. 10pm to 7am)
42. Please select all of the items below that describe your support system. (All questions are optional.)
43. Have you ever been bitten by a tick?
44. Please check off any of the following that you may have experienced in the last 3 months or so.
PLEASE READ
The above information is complete and correct to the best of my knowledge. While I'm consulting with Anne, I understand that it's my responsibility to inform her if my health condition changes. I also understand that services at BuzzNutrition do not take the place of a physician’s care and that Anne Buzzelli does not diagnose ailments. Rather, she brings attention to patterns that may indicate an imbalance in health (via questions and lab testing) and then suggests foods, nutrients, herbs and lifestyle changes that may help your body regain balance. BuzzNutrition’s HIPAA Privacy Policy is available at www.BuzzNutrition.com/services.
If you haven't already set up an appointment, please visit https://www.schedulicity.com/scheduling/BYUJ5N/services to make an appointment.
Survey Software powered by Alchemer
Survey Software