Prevail Over Cancer Coaching Assessment Packet

  • 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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  • May I Text Messages to Your Mobile Phone?
  • May I Leave Messages on Your Mobile Phone?
  • May I Leave Messages on Your Home Phone?
  • May I Leave Messages on Your WhatsApp Number?
  • May I Text Messages to Your WhatsApp Number?
  • Prefered phone communications
  • May we add you to our Prevail Over Cancer Email Newsletter?
  • Would you prefer that information be
  • Do you use tobacco or vape?
  • Do you use marijuana or vape?
  • Do you use alcohol?
  • Which do you consume most often?
  • How many servings of fruits and vegetables do you consume each day?
  • How often do you exercise?
  • Pregnant?
  • Breast feeding?
  • Do you drink filtered or bottled water?

  • Medical History

  • Medical history

  • Health Care Providers

  • May we contact your healthcare provider(s) for additional information or inform them of health concerns we may have?

  • 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.

  • I have read, understood, and agreed with the information I have entered on this form, and to the best of my knowledge, it is correct.*

  • 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)

  • 1. Are you presently taking prescription or non-prescription drugs?
  • 2. Are you presently taking one or more of the following drugs?
  • 3. If you have used or currently use prescription drugs, which of thefollowing scenarios best represents your response to them:
  • 4. Do you currently use or, within the last 6 months, have you regularly used tobacco products?
  • 5. Do you have strong negative reactions to caffeine or caffeine-containing products?
  • 6. Do you commonly experience “brain fog,” fatigue, or drowsiness?
  • 7. Do you develop symptoms on exposure to fragrances, exhaustfumes, or strong odors?
  • 8. Do you feel ill after you consume even small amounts of alcohol?
  • 9. Do you have a personal history of
  • 10. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?
  • 11. Do you have an adverse or allergic reaction when you consumesulfite-containing foods such as wine, dried fruit, salad barvegetables, etc.?

  • Alkalizing Assessment

  • 1. Do you have a history or currently have kidney stones or dysfunction?
  • 2. Have you ever been diagnosed with a condition known as hyperkalemia (elevated potassium)
  • 3. Are you currently on diuretics or blood pressure medication?
  • 4. Do you have a history of more than two UTIs (Urinary Tract Infections) per year.

  • 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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  • Do you have trouble initiating your bowel movement, yet the stool is not too large or too hard?
  • Does abdominal discomfort or cramping ever accompany bowel movements?
  • Does abdominal discomfort or cramping ever accompany bowel movements?
  • Have you ever been diagnosed with a dental, gum, mouth, stomach, liver, gallbladder, pancreas, intestinal or bowel disorder or disease?
  • Have you had or do you have hemorrhoids or varicose veins?
  • Do you make a conscious effort to eat a high fiber diet?
  • Do you usually pay attention when nature calls, have a BM (bowel movement)?

  • 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: