Consultation with Patrick Form
Please fill the following consultation form. Patrick will contact you shortly to let you know when your consultation will be ready.
Firstname
First Name
Last Name
E-mail
example@example.com
Phone number with international dialing code
Country
Date of birth DD/MM/YY
Weight in kilograms
Height in centimeters
What is your main health concern?
Any other health problems
*
What medication are you taking
What health suplements/herbs do you take
Do you exercise? Which and how often?
How much stress are you under?
A little
Medium
A lot
How often do you eat chocolate?
Daily
2 or 3 days a week
Almost daily
Never
How many coffee, or caffeinated tea, do you drink daily?
1 or 2
3 to 5
6 or more
I never drink caffeniated products
Do you eat organic food at least more than 4 days each week
Yes
No
Never
How often do you eat fruits?
Daily several fruits
Daily one only
2 or 3 times a week
Rarely
Never
How often do you eat seeds, nuts, avocados, hummus, coconut flesh, milk or other oily produts?
Daily
2 or 3 a week
Almost daily
Never
I use oil for frying or in salad
Daily
2 to 4 times a week
Rarely
Never
I eat eggs
Daily
2 or 3 a week
Almost daily
Never
I eat fish or other sea food
Daily
Almost daily
Rarely
Never
I eat dairy products (milk, cheese, yoghurt, cream, etc.) from cows, goats, sheep, Ghee, etc.
Daily
2 or 3 times a week
Almost daily
Never
I eat gluten products such as bread, cakes, biscuits, flour products, pasta or grains (except quinoa, millet and brown rice)
Daily
Almost daily
Never
I eat chicken
Daily
2 or 3 times a week
Almost daily
Never
I eat beef
Daily
2 or 3 times a week
Almost daily
Never
Other meat you eat
I alway check the labels on products I buy to see if they contain chemicals, sugar, etc.
Yes, always
Rarely
Never
I smoke
Yes
No
I drink alcohol
Daily
2, 3 or 4 times a week
Rarely
Never
IMPORTANT. If you have only recently changed your diet, please state when and explain the changes you made.
How did you hear about my consultation?
Word of mouth
Search engines
Facebook
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Other or can't remember
Please verify that you are human
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