Pre-Consultation Form
"This form is to learn more about you and personalize your experience."
Name
*
Name
Last Name
Date of Birth:
-
Año
-
Mes
Día
Date
"Place of Birth:"
Age:
Gender:
Marital Status:
Current Weight:
Zodiac Sign:
Religious Belief:
Favorite Drink:
Favorite Dish:
Height:
Weekly Rest Days:
Seleccione
1
2
3
4
5
6
7
Favorite Hobby:
*
Purpose of Visit:
Preferred Date for Your Appointment:
Type of Work You Do:
Are you allergic to any food or medication?
Any current medical condition or illness you are being treated for:
Do you engage in physical activity?
No
Regularly
Every Day
Do you consume alcohol?
No
Yes
Do you smoke?
No
Yes
What is your desired weight?
What is your desired clothing size?
Do you have difficulty digesting red meat or does it take a long time to digest? If you don't eat red meat, please indicate so.
No
Yes
Does consuming saturated fats or fatty foods, such as pork, chops, or fried foods, cause digestive problems for you?
No
Yes
Does eating late at night hinder digestion?
No
Yes
Does eating food after a certain hour at night affect my ability to sleep? Do I experience difficulty falling asleep?
No
Yes
I have a light sleep, and loud noises or extreme movements can easily wake me up. Do I have a shallow sleep?
No
Yes
Send
Should be Empty: