New Client General Information Form

***New Client* *General Information Form***

Disclaimer: I understand that nutritional balancing is a means to reduce stress and balance body chemistry. It is not intended as diagnosis, treatment or prescription for any condition or disease.

Name

Email Address

Date of Birth

Age

Sex Sex M F

Address

City

State

Postal Code

Country

Home Phone

Business Phone

Height

Weight

Occupation

How were you referred?

What are your main health concerns or conditions?

Please list any medications or food supplements you are currently taking.

Please list any recent medical test results you have, such as blood tests.

Any past surgeries and dates.

Please list illness in your family such as heart disease, cancer, TB, diabetes, arthritis, etc.

Diet: What are examples of typical breakfasts for you? (Food and Beverages)

Diet: Mid-morning Snacks? (Food and Beverages)

Diet: What are typical lunches for you? (Food and Beverages)

Diet: Mid-afternoon Snacks? (Food and Beverages)

Diet: What are typical dinners for you? (Food and Beverages)

Diet: Evening Snacks? (Food and Beverages)

How often and what kind of exercise do you do?

About how many hours of sleep do you get per day?

Alcohol (Type, Amount in Ounces, and How Often):

Tobacco (Type and How Often):

Recreational Drug use (Type and How Often):

Joint Pain Joint Stiffness Arthritis, Osteo Arthritis, Rheumatoid Muscle Pain Muscle Weakness Muscle Cramps Bursitis Fractures Osteoporosis Gout

Sweet Cravings Sugar Reactions Irritable Before Meals Can't Skip Meals Hypoglycemia Crave Starches Fat Cravings Other Food Cravings Food Allergies Excessive Hunger No Hunger Diabetes

Rapid Heart Rate Skipped Heart Beats Heart Palpitations Heart Attack Poor Circulation Dizziness Low or High Blood Pressure Angina High Triglycerides

Arteriosclerosis High Cholesterol Cough Bronchitis Asthma Post-nasal Drip Sinus Congestion Allergies Emphysema

Fatigue Hypothyroidism Low Body Temperature Cold in Winter / Dry Skin Tend to Gain Weight Hyperthyroidism Acne Eczema

Fungal Infections / Candida Psoriasis Hives Hair Loss Slow Wound Healing Cataracts Glaucoma Meniere's Disease Tooth Decay Excessive Plaque on Teeth Gum Disease

Infections / Viruses Tumors / Cancer Multiple Sclerosis Parkinson's Disease Scleroderma Fear Anger Anxiety Bipolar Disorder Brain Fog Confusion Depression Irritablity Mind Races Mood Swings Obsessive / Compulsive Panic Attacks Poor Memory Schizophrenia Trouble Sleeping Suicidal Thoughts Autism Attention Deficit Hyperkinesis Dyslexia Seizures Learning Disability Mental Retardation Delayed Development

Bladder Infections Kidney Infections Trouble Urinating Frequent Urination Painful Urination Kidney Stones Water Retention Sinus Headaches Tension Headaches Migraine Hedaches

Neuritis Eye Diseases Constipation Diarrhea Intestinal Gas Bloating Heartburn Ulcer Stomach Pain Colitis Gall Stones Fissures Hemorrhoids Cirrhosis Diverticulitis Tend to Gain Weight Tend to Lose Weight

Anemia Easy Bruising

Dental Amalgams Drug Addiction Alcoholism Smoking

Premenstrual Syndrome Water Retention Cramps No Menstration Heavy Periods Light / Irregular Periods Ovarian Cysts Fibroid Tumors Abnormal Pap Smear Menopause Fibrocycstic Breasts Breast Tumors Yeast Infections Hot Flashes Currently Pregnant Abuse Rape

Prostate Problems Impotence Infertility

Vegetarian Vegan

Additional Comments or Symptoms

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