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nutrition & wellness
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FREE GUIDE
nutrition & wellness
contact
the immunity babe
anti-inflammatory & immunity boosting living
Gut-Health Nutrition Audit Forms
FORM #1 : ABOUT YOU
Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Order Number
*
GI Symptoms - are you experiencing any of the following gut-related issues? (check all that apply)
Diarrhea/loose stool
Constipation
Gas
Bloating
IBS
Stomachaches
Acid reflux/indigestion
Food sensitivities
Additional Symptoms - are you experiencing any of the following additional symptoms? (check all that apply)
Frequent colds/weakened immune system (sick 4+ times per year)
Constant mucus/phlegm (even when you're not sick)
Mouth sores
Asthma
Acne
Eczema or other skin conditions
Joint pain
Autoimmune symptoms
Chronic fatigue
Anxiety
Depression
Brain fog/attention disorders
Intense sugar cravings
Please list any additional symptoms you’re experiencing or any important information related to the above symptoms you’ve checked off:
Do you currently have any diagnoses or health conditions, especially ones that impact what you can and cannot eat?
*
Yes
No
If yes, please explain:
Do you have any food allergies? (I am not referring to sensitivities, which can often be corrected. Here, I am referring to true, severe food allergies that result in hives, breathing difficulty, etc.)
*
Yes
No
If yes, please explain:
Do you use any medications that cannot interact with certain foods?
*
Yes
No
If yes, please explain:
Is there a special diet that you follow? (i.e. vegetarian, pescatarian, etc. This information allows me to make appropriate recommendations for you)
*
Yes
No
If yes, please explain:
Goals - Here, I want to discuss your goals. What do you hope to get out of changing your eating habits? Please describe below:
*
Please include any additional questions or concerns you’d like me to address:
Please share any additional information you think would be beneficial:
Thank you!
FORM #2 : 5 DAY FOOD TRACKER
Name
*
First Name
Last Name
Email
*
DAY 1
*
DAY 2
*
DAY 3
*
DAY 4
*
DAY 5
*
Thank you!