Prevail Over Cancer Coaching Assessment Packet Logo

  • Coaching Assessment Packet

    Please complete this information and make arrangements for your coaching appointment session.

  • Confidential Coaching Client Information

    This coaching consultation is intended to improve the use of supplements, bio-identical hormones, prescription, nonprescription medicine and products, non-drug approaches to self-care and/or referral to other health care providers. I do not diagnose or treat health conditions. Diagnosis and treatments are available from your healthcare provider.
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  • Medical History

  • Health Care Providers

  • Medications and Treatments

  • Certification Statement

  • Nutritional Coaching Consultation Disclaimer: By signing below, you understand that any products, supplements, or recommendations discussed or provided during this assessment and consultation have not been evaluated or approved by the U.S. Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any disease. The information shared is based on general nutritional principles and professional experience. Participation in this consultation does not create a healthcare provider-patient relationship. The consultant is not a licensed medical professional and cannot provide medical diagnoses or treatments. Individual results may vary based on personal factors, and any actions you take based on the information provided are at your own risk. This consultation is for educational purposes. It is essential to consult with your healthcare professional before changing your diet, exercise, or supplement regimen. By participating in this nutritional consultation, you acknowledge and agree to these terms and understand the limitations of the information provided. Always consult a healthcare professional before significantly changing your lifestyle, diet, supplement, or health practices.

    Certification Statement of Coaching Client: Clinical Nutritionist coaching consultation services are available via virtual appointment, telephone, Zoom, FaceTime, and other virtual communications. Consultation fees are based on the time spent with the Clinical Nutritionist. They range from $45 for 15 minutes to $180 for 60 minutes. Payment is due before the services are rendered. Appointment scheduling and payment are accepted at www.PrevailOverCacner.com/coaching.

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  • Medical Symptoms Questionnaire (MSQ)

  • Rate each of the following symptoms based on your typical health profile for the past 30 days.

    Never or rarely have the symptom

    Occasionally have it; the effect is not severe

    Occasionally have it; the effect is severe

    Frequently have it; the effect is not severe

    Frequently have it, the effect is severe

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  • Xenobiotic Tolerability Test (XTT)

  • Alkalizing Assessment

  • Elimination Assessment Brief

    Colon / Bowels
    1. My bowels move   
      1.    times per day;   
      2.    times per week (on average).
    2. Laxative use:  
      1.  times per day;   
      2.  times per week;   
      3.   times per month;    
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  • HEALTH APPRAISAL QUESTIONNAIRE

    This questionnaire asks you to assess how you have been feeling during the last four months. This information will help you keep track of how your physical, mental and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and family life, level of physical activity and time spent on personal growth. All information is held in strict confidence. Take all the time you need to complete this questionnaire.

  • For each question below, check the number that best describes your symptoms:

    0 = No or Rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less).
    1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger.
    4 = Often—Symptom occurs 2-3 times per week or with a frequency that bothers you enough that you would like to do something about it.
    8 = Frequently—Symptom occurs 4 or more times per week or you are aware of the symptom every day, or it occurs regularly on a monthly or cyclical basis.

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  • Virtual Nutrition Physical Assessment

    The more information I know, the better I can assist.

  •  Hair:
     Skin:
     Eyes:
     Fingernails (no artificial nails or fingernail polish if possible):
     Cuticles:
     Tongue:
     Adrenal Blood Pressure:
        Resting Sitting Blood Pressure ____/____
        wait 3 minutes, stand and immediately take Blood Pressure ____/____
     Resting Heart Rate Pulse: _____ BPM
        Resting Pulse Ox (oxygen saturation): _____
     Fasting Early Morning Saliva pH Results: ____
        Fasting Early Morning Urine pH Results: ____
     Zinc Taste Test Results: ____
     Iodine Paint Results: ____

  • Should be Empty: