Any serious illnesses/hospitalizations/injures?

Do you take medications or supplements?

How many ounces of water do you drink daily? What types: Circle all that apply; tap/ mineral/ spring bottled / distilled /purified /alkaline /flavored

What types of foods do you crave? Circle all that apply Salty/Chocolate/ Sweet/ Breads /Other

(1=lowest energy level:10=highest)

I understand that I am here to learn about nutrition and better health practices. I will be offered information about food, movement, dietary theories supplements to guide general health.

Iunderstand that those who counsel and coach me are not medical doctors, and I am not here for medical diagnostic purposes or treatment procedures. I am not inquiring or on this visitor subsequent visit as an agent for federal, state, or local agencies or on a mission of entrapment or investigation.

The services performed are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health and do not involve the diagnosing, treatment, or prescribing of remedies for disease.