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Functional Nutrition
FM (Functional Nutrition Intake form)

Discover the transformative power of functional nutrition on your journey to optimal health and vitality. Embracing the philosophy that every bite you take is a step towards nourishing your body, functional nutrition delves deep into the intricate relationship between what you eat and how you feel. It’s not just about counting calories; it’s about unlocking the potential of food to support your unique biological processes. Imagine a world where your meals are tailored not only to tantalize your taste buds but also to fortify your immune system, balance your energy levels, and ignite your inner radiance. Our mission is to guide you through this personalized nutritional adventure, where science meets flavor, and where each ingredient serves a purpose beyond taste. Embark on this enriching experience with us and witness firsthand how functional nutrition can be the compass guiding you towards a revitalized life

Genetic Background *
Do you currently follow any of the following special diets or nutritional programs? (Check all that apply) *
Other
Nutrition
Do you have sensitivities to certain foods? *
If yes, list food and symptoms:
Do you have an aversion to certain foods? *
If YES What?
Are there any foods that you crave or binge on? *
If yes, what foods?
Do you eat 3 meals a day? *
If no, how many
Does skipping a meal greatly affect you? *
How many meals do you eat out per week? *
Check the factors that apply to your current lifestyle and eating habits: *
Please record what you eat in a typical day for breakfast: *
Please record what you eat in a typical day for launch: *
Please record what you eat in a typical day for dinner: *
Please record what you eat in a typical day for snacks: *
Please record what you eat in a typical day for fluids: *
How many servings do you eat in a typical week of below foods:
Fruits (not juice) *
Legumes (beans, peas, etc) *
Dairy/Alternatives *
Cans of soda (regular or diet) *
Vegetables (not including white potatoes) *
Red meat *
Nuts & Seeds *
Fats & Oils *
Sweets (candy, cookies, cake, ice cream, etc.) *
Do you drink caffeinated beverages? *
If yes, check amounts: Coffee (cups per day)
If yes, check amounts: Tea (cups per day)
If yes, check amounts: Caffeinated sodas—regular or diet (cans per day)
Do you have adverse reactions to caffeine? *
If yes, explain:
When you drink caffeine do you feel
Smoking
Do you smoke currently? *
If yes, How many packs per day
If yes, Number of years
What type?
Have you attempted to quit? *
If yes, using what methods:
If you smoked previously: Packs per day:
Are you regularly exposed to second-hand smoke? *
Alcohol
How many alcoholic beverages do you drink in a week? (1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits) *
Previous alcohol intake? *
Have you ever had a problem with alcohol? *
If yes, when? And explain the problem
Have you ever thought about getting help to control or stop your drinking?
Other Substances
Are you currently using any recreational drugs? *
If yes, type:
Have you ever used IV or inhaled recreational drugs? *
Relationship
Marital status: *
With whom do you live? (Include children, parents, relatives, friends, pets)
Do you have resources for emotional support? *
If yes (Check all that apply)
Other
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Elumind Centres For Brain Excellence is a private out-patient healthcare centre specializing in optimizing brain functions through various neurotherapeutic modalities. We deliver a comprehensive, personalized case managed collection of holistic therapies that create long-lasting lifestyle changes.

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CONTACT

(604) 220-8866

© 2023 Elumind Peak. All Rights Reserved.

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