By Herbun Energy
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Current Weight (pounds)
Reason for the consultation; please be detailed.
What are your health goals?
Do you have any preference in food diet?
Have you followed any diet trend?
Was the diet trend you followed effective?
Please share the diet trend you followed and the effectiveness here.
Leave blank if the answer is no.
Do you take any herbs or herbal products daily?
If yes, please share what items here so that we are aware about it.
Do you have any allergies? If yes, please list them below:
Are you currently taking any medications? If yes, please list them below:
This includes vitamins, supplements, and other medications you're taking
Please check below if you have any of the current health conditions:
Are you smoking?
Are you drinking alcohol?
Are you a vegetarian?
What caffeinated beverages are you drinking?
Do you go to the gym? How often do you exercise?
Meal Plan / Nutritional Log: In your estimate, what are the foods and liquids are you usually taking in a daily basis?
We take great pride in offering our customers high-quality consultation services. As a family-owned business, we kindly ask that you consider making a donation to support and sustain our exclusive service. Your contribution will help us to continue providing exceptional consultation services and ensure our business thrives for many years to come.
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