Client Profile

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First & Last Name

Date of Birth

Email

Height & Weight

Phone

Have you been diagnosed with any medical conditions, or suffering from an illness or injury?

No

Yes

Are you diabetic or prediabetic?

No

Yes

What is challenging your health at this time? (Please list any symptoms experienced in the last six months)

Please list all medications/supplements

Do you have any of the following?

Achy Joints

Indigestion/Gassiness

Frequent Headaches

Extreme Fatigue

Sinus Problems/Allergies (Food or seasonal)

Back Problems

Carpel Tunnel

Dizziness

Racing Heart

Cold Hands or Feet/tingling

Shaking or Tremors

Itching all over/Skin rashes

Tonsils removed

Surgery or removal of body parts/organs

Chicken pox vaccine as a child

Silver or grey filings

Recent Vaccine

List any food allergies/Intolerances

What is your blood type?

I attest that all the information I have provided is true. I understand it is in my best interest to disclose any medical conditions and medications that I have or may be taking so my natural health counselor can check for possible interactions.-This program is not intended to provide medical advice, treat or diagnose any conditions. The sole purpose of this program is to teach me how to apply natural measures known for their healing properties in a way to include them into my daily life. **ALWAYS check with your physician first before beginning any restrictive program!**

Initials

Office notes

Thanks for submitting!

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