Nutritional Health Survey

Nutritional Health Survey

The following questionnaire is designed to help me explore your nutritional history.  Each and every person’s biochemistry shares some similarities. Each person’s background, personal history and response to stressful factors, however, create unique chemical patterns and characteristics. As your nutritionist, I will utilize the information from this questionnaire as well as other assessment forms to help determine the proper diet and nutritional supplementation that is best suited for your particular needs. Due to circumstances that may be beyond your control, I realize that some of the information may be impossible or difficult for you to answer or determine. Although this questionnaire is by no means inclusive, it does offer me additional information that can help us work together as an investigative team to design the nutritional program that is best suited for your individual needs. If there is additional information that you would like to share, please feel free to add this to your own form.

It is very important that I know your blood type. If you do not know your blood type, we have an easy testing kit that you can do in your own home or in our spa the day of your appointment.

I appreciate your efforts to work hand-in-hand with me to achieve your nutritional goals of enjoying health, vitality, and longevity.

Please be sure that on the day of any assessments you do not take any nutritional supplements before coming to your appointment.


Michele Johnson
LMT & Nutritionist

This survey is thorough so it’s lengthy to complete online.    We suggest setting aside 5-10 minutes to complete in entirety.  Note, that due to the length of this form, you are not able to go back and complete items later.  Please answer to the best of your ability or skip items you’re unsure about.  We can cover these during our session.  If you would rather Print, Complete and Fax this information, you can DOWNLOAD HEALTH SURVEY.

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