Name
Address
Phone: Work Cell Home
Email address How often do you check email?
Occupation Previous occupation
Birth date: Current weight Height
What is your ancestry?
What is your blood type?

What is your immediate family medical history (parents,grandparents, siblings)?

What is your typical diet?
 Omnivore (eat everything) Vegetarian (eat animal by-products like eggs and cheese) Pesco-Vegetarian (consider yourself vegetarian but eat fish) Vegan (no animal or by-product in food or clothing yet eat some both cooked & raw) Raw-Live/ Vegan (eat predominantly fresh, ripe, raw, organic, sprouted seeds, nuts, fruits, vegetables, seaweeds (greater portion of diet 80% or more)

Other, please explain:
Do you have any food allergies?
What percentage of your food is home cooked or prepared raw at home?
Where do you get the rest from?

What are your three most frequented restaurants (dine in or delivery)

Do you sleep well?
Do you wake up at night?
What times?
What time do you generally wake up in the morning?
Do you drink coffee soda or tea ? Do you eat chocolate (Please enter which apply) How often?
Are you caffeine sensitive?

Do you use artificial sweeteners or drink diet soda?  Yes No

Do you drink alcohol? If so, how much and what type?

Do you smoke tobacco?  Yes No

If so, how much?

If you have stopped smoking or drinking, when did you quit? Please specify.

Do you use recreational drugs? If so which?
How often? If you have stopped, when did you quit?

Do you take supplements, herbs or medications?

Are you currently under a Doctor’s care?  Yes No

Dr.’s name and Phone
Diagnosis or recent medical info?

Do you have any allergies to food or medications?

Have you ever had surgery, or been involved in an accident?  Yes No

Please explain
Do you exercise? How often and what type?
How often do you have a bowel movement in 24 hrs?

Do you have experience constipation?  Yes No

Difficult digestion?  Yes No

Excessive hunger?  Yes No

Poor Appetite?  Yes No

How much water do you drink per day?

Has your weight changed in the past year?  Yes No

If Yes, how much?

Weight 1 year ago (approx) Weight 5 years ago (approx)

Do you get headaches?  Yes No
Experience fatigue?  Yes No
Do you get backaches?  Yes No

Have you ever had a colonic?  Yes No

If so, when?

Are you open to doing colonics? Enemas?  Yes No

How many times have you done a cleanse or fast?

Are you involved in any alternative therapies
(for example Chiropractic, Acupuncture, Reiki)
If so, which and how often?

Women only.

Is your menstrual cycle normal?

Do you experience PMS?

Do you have bad cramping during your period?  Yes No

Please explain

Are you or have you ever taken birth control pills?
If so, when and for how long?

Any possibility you are pregnant?  Yes No

Are you attempting to become pregnant?  Yes No

What is motivating you to make changes regarding your health?

What are your primary health concerns?

What are your health goals?

Who referred you, and/ or how did you hear about my services?

Please provide any other information you think may be relevant.
All information is strictly confidential.

What foods do you crave?

What foods make you feel best?

What are your comfort foods?

What foods did you eat as a child?

Breakfast
Lunch
Dinner
Snacks
Liquids

What about one year ago?

Breakfast
Lunch
Dinner
Snacks
Liquids

What about currently?

Breakfast
Lunch
Dinner
Snacks
Liquids

 

Disclaimer of Health Care Related Services

The Consultant encourages you to continue visiting with, and be treated by, your healthcare professionals, including, without limitation, your physician. You understand that the Consultant is not acting in the capacity of a doctor, licensed dietician-nutritionist; massage therapist, psychologist or other licensed registered professional. Accordingly, you understand that the Consultant is not providing health care, medical care or therapy services and will not diagnose, treat or cure in any manner whatsoever, any disease, condition or other physical or mental ailment of the human body. The client has chosen to work with the Consultant and understands that the information received should not be seen as medical or nursing advice and is certainly not meant to take the place of your seeing licensed health professionals.

Personal Responsibility and Release of Health Care Related Claims

The Client acknowledges and takes full responsibility for your life and well being, as well as the lives and well being of your family and children (where applicable), and all decisions made during and after this program.

*I accept an electronic signature typed in space below.
An electronic signature is equivalent to a written signature and thus legally binding.
*Client name

*Signature
Date

THANK YOU!