• Date of Appointment:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth: year/mm/dd*
     - -
  • Sex:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • If you chose 'other phone', indicate whether it's a work or home number.
  • Preferred method of contact*
  • How did you find us?*
  • Rows
  • Were you born by C-SECTION?*
  • Were you BREASTFED?*
  • Do you have any ALLERGIES?*
  • Allergy Type(s)*
  • How many times have you been on ANTIBIOTICS in your life?*
  • Have you ever lived in a home with MOLD?*
  • Are you retired?:*
  • Are you (or were you previously) exposed to any work-related chemicals?*
  • How many hours/day is your PHONE or laptop on or very close to your body?*
  • Do you SMOKE the following?*
  • Do you DYE your hair?*
  • Do you use FLUORIDE toothpaste?*
  • Breakfast*
  • Lunch*
  • Supper*
  • Snacks*
  • Please record your daily coffee consumption. Leave blank if you do not drink coffee.
    Rows
  • How often are you drinking the following beverages?
    Rows
  • How much water do you drink daily? Answer in EITHER litres or cups.*
    Rows
  • Please check the TYPES of water you drink.
  • How many BOWEL movements do you have daily?*
  • How many hours/day are you SITTING?*
  • Describe your ENERGY level.*
  • Describe your SLEEP.*
  • Rate your STRESS levels in the past 6 months.*
  • Have you had any recent or drastic WEIGHT CHANGE?*
  • Have you ever done any CLEANSES?*
  • Check all that apply:*

  • CONSENT AND ACKNOWLEDGMENT

  • I, the undersigned, hereby understand and acknowledge that Grant M. Derkatz is not a medical practitioner and in particular that he:

    A) does not hold himself out as being able to diagnose, treat, operate or prescribe for any human disease, pain, injury, disability or physical condition;

    B) does not offer or undertake by any means or methods to diagnose, treat, operate, prescribe for any human disease, pain, injury, disability or physical condition, and;

    C) cannot and will not give medical advice.

  • I, the undersigned, hereby confirm and acknowledge:

    A) I will be charged a $100 fee if I cancel an appointment (with less than 24 hours' notice) or do not show up for an appointment.

    B) all information from, or communication with, Grant M. Derkatz are at my own request, with full knowledge of the above particulars, and;

    C) no guarantees have been made to me concerning the results that may be obtained as a result of my consultation with Grant M. Derkatz.

  • The use of any recording devices is strictly prohibited WITHOUT the express written consent of Healthworks Nutrition Centre

  • Healthworks Nutrition Centre will not share your health information without your consent.
  • Dated this*
     - -
  • Are you (the client) a minor (under 18 years old)?*
  • Should be Empty: