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Health and Nutrition Evaluation

Providing the following information will allow a better understanding of your condition, and enable us to help you more. Explain fully where necessary.

Health and Nutrition Evaluation Form  (37 KB)

First Name
Last Name
Street Address
Apartment, suite, unit etc.
State / Province / Region (if applicable)
Postal Code / Zip Code
Home Phone
Cell Phone
E-mail Address
Birth Date
Marital Status
Religion Preference


Give medical history - names and dates of past ailments, operations (anything you feel significant, including past complaints).
When did you last consult a physician?
For what reason?
What are you currently being treated for?
What specific conditions would you like this consultation to address?
List all medicine, pills, or drugs you are taking now
List mineral and/or vitamin supplements you are taking/how many and how often
Do you have indigestion?
How Often?
What foods tend to cause indigestion, bloating or gas?
How often do you have bowel evacuations?
Color & Texture
Do you have Diarrhea?
What color is your urine usually?
Do you wear eyeglasses?
Contact lenses?
How many years?

What health ailments, illnesses or challenges have you suffered with in the past and/or are currently sufferng with?

(Absent Minded, Excessive Hunger, Lumbago, Acne, Excessive Worry, Mental Disorder, Alcoholism, Faint When Hungry, Motion Sickness, Allergies, Fatigue, Nausea, Anemia, Feels Shaky if Hungry, Nervous Disorder, Appendicitis, Foul Smelling BM, Night Blindness, Arthritis, Foul Smelling Urine, Pain w/bowel movement, Asthma, Frequent Colds, Poliomyelitis, Bad Breath, Frequent Kidney Infections, Prostate Trouble, Cancer , Frequent Lower Bowel Gas, Respiratory Problems, Chest Pains, Frequent Urination, Rheumatic Fever, Chills/Cold Skin, Gallstones, Sexual Disorders, Cold Hands/Feet , Hay fever, Sinusitis, Constipation, Headaches, Skin Problems, Crave sweets/coffee, Heart Disease, Sluggish in the A.M., Depression, Heart Pounds Hard, Swollen Glands, Diabetes, Hemorrhoids , Too Fast Digestion, Diarrhea, High Blood Pressure, Tuberculosis, Difficulty Breathing, Hot Most of the Time, Ulcers/Colitis, Digestive Disorders, Indigestion/Heartburn, Venereal Infection, Dizziness, Insomnia, Wake Up Tired, Eat When Depressed, Irritable before Meals, Weight Problem, Eat When Nervous, Itching of the Nose, Eating relieves fatigue, Itching of the Rectum, Eczema, Kidney Stones, Emphysema, Light-headedness, Excessive Fear, Low Blood Pressure)

Enter health ailments, illnesses or challenges here...
List all medicine, pills, or drugs you are taking now


What hours do you work?
Health of spouse (if applicable):
How many children do you have?
Health of children
Recreational activities enjoyed
Hours per week viewing TV
Do you often feel guilty about past mistakes?
Do you worry about the future?
Do you have stress?
Do you suffer with depression?
Check the following categories which cause stress
On a scale of 1 to 10 rate your stress level (1= very little stress and 10=an extreme amt. of stress)?
Do you enjoy the work that you do?
If Not, Explain
Are you developing your mental and spiritual capabilities by daily study, meditation and prayer?
Are you involved in some type of activity in which you are helping others
The following space is provided for those who would like to elaborate more on the causes of their stress, depression and other negative emotions.


How many hours daily do you spend out of doors?
Do you sleep with your windows closed?
Are you able to breathe fresh air while you are working?
Is the building where you work a none-smoking facility?


How often do you exercise?
Describe the exercise:
How do you feel after you exercise?


How much time daily do you spend out of doors in the sunlight?
Do you oftern get sunburned?
Do you visit tanning beds?
Are you afraid of getting skin cancer?


What time do you go to bed?
What time do you awaken?
What time is your last meal before retiring?
Do you snack just before bedtime?
Do you wake up during the night and snack?
If so, what do you eat?
Do you have trouble sleeping?


How much water do you drink daily?
What type? (spring, filtered, distilled, tap)

Check below the beverages you drink and indicate how much of each



#OF Glasses, Cans or Bottles Daily

What is the usual color of your urine?
Explain your understanding of the principles of hygiene


Do you ingest caffeine in any form?
If so, for how many years?
Have you ingested caffeine in the past?
For how many years?
If so, when did you stop?
Do you smoke or chew tobacco?
Indicate which
If so, for how many years?
Have you used tobacco in the past?
For how many years?
If so, when did you stop?
Do you drink alcohol?
If so, what kind?
For how many years?
Have you drank alcohol in the past?
For how many years?


Do you overeat?
Do you feel stuffed after your meals?
Do you eat between meals?
Do you drink with your meals?
If so, what liquids?
Do you wear removable dentures or plates?
Do you eat fast?
How long does it take you to eat?
Do you have a peaceful environment at meal times?
Do you have set meal times?
Are you following any special diet?
Explain what type
Do you eat animal products?
If so, what kind?
How Often?
Do you eat dairy products?
What kind of dairy products
Do you eat desserts, candy or other sweets regularly?
Explain how often and what Type
What time do you eat breakfast?
What foods do you usually eat?
How often do you eat a tossed green leafy salad?
How often do you eat steamed or cooked vegetables?
How often do you eat fruits?
How often do you eat soup or stew?
What time do you eat lunch (dinner)?
What foods do you eat?
What time do you eat supper?
What foods do you eat?


Full Name
E-Mail Address
Suburb / City
Contact Phone


Submit $125 donation to complete the consulation process.

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