• Date of Appointment:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Has your email or phone # changed since your last appointment?*
  • Format: (000) 000-0000.
  • Since your last visit have you noticed any of the following?*
  • Are you currently experiencing any specific health concerns that you want to focus on?*
  • Have any of your MEDICATIONS/SUPPLEMENTS CHANGED since your last visit?*
  • How much water do you drink daily? Answer in EITHER litres or cups.*
    Rows
  • Please record your daily coffee consumption. Leave blank if you do not drink coffee.
    Rows
  • How often are you drinking the following beverages?
    Rows
  • Rate your STRESS level in the past month.*
  • Do you smoke or vape (Smoking includes cigarettes or marijuana)?*
  • How Often do you Smoke/Vape the Following?*
    Rows
  • How many BOWEL movements are you having daily?*
  • Describe your ENERGY level in the past month.*
  • Describe your SLEEP in the past month.*

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

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

     

    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: