What is your immediate family medical history (parents,grandparents, siblings)?
Do you use artificial sweeteners or drink diet soda? Yes No
Do you smoke tobacco? Yes No
If you have stopped smoking or drinking, when did you quit? Please specify.
Do you take supplements, herbs or medications?
Are you currently under a Doctor’s care? Yes No
Do you have any allergies to food or medications?
Have you ever had surgery, or been involved in an accident? Yes No
Do you have experience constipation? Yes No
Difficult digestion? Yes No
Excessive hunger? Yes No
Poor Appetite? Yes No
Has your weight changed in the past year? Yes No
If Yes, how much?
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?
Do you have bad cramping during your period? Yes No
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?
What about one year ago?
What about currently?
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.