Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

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Medical Diagnosis, please check off all that may apply:

High blood pressure

Diabetes

Arthritis

Gastrointestinal disorders

Menstrual problems

Endometriosis/Fibroids

PCOS

Cardiovascular disease

Depression

Anxiety

Eating Disorder

Gall bladder disease

Renal disease

Asthma

High cholesterol

Thyroid condition

Liver disease

Cancer

Skin problems

Sleep Apnea

Check the answer that best applies to you:

I plan meals for the week

I plan meals 1-2 days ahead of time

I plan dinner at breakfast time

I plan dinner on the way home from somewhere

I drop into the store and then figure out what to eat

For the most part, I don’t plan at all and just grab whatever I am in the mood to eat

Check the answers that best apply to you:

I feel easily fatigued

I tend to be a perfectionist

I feel lethargic

I tend to have dry skin

I have skin rashes

I have oily
 skin

I tend to be constipated

I have regular bowel movement, my feces tend to be yellowish

I have one bowel movement per day sometimes I feel itching on my anus region

I feel anxious, and worry too much

I often feel frustrated, angry, irritable and/or impatient

I feel I can be possessive or over-attached

I often feel restless and/or unsettled

I tend to be demanding or critical

I often feel complacent or dull

I weight less than my ideal body weight

I carry excess weight

I have irregular sleeping patterns or suffer from insomnia

I have light but restful sleep

I tend to oversleep

I feel like my hands and feet are always cold

I feel uncomfortable in the hot weather

I have prematurely thinning and/or gray hair

I have an irregular appetite, frequent belching, hiccup or a sense of constriction. I might forget to eat sometimes

I have great appetite. I might experience burning sensation or presence of ulcers. I rarely go without eating

I tend to have slow digestion. Noticeable loss of appetite, sweet or mucoid belching

Severe, throbbing, biting, tearing, migratory or intermittent pain

Medium, burning, sharp, steaming, or tenderness to touch pain

Less, heavy, dull, or constant pain

I haven’t experienced any pain in a long time

Feeling bloated, frequent fullness, pain or burning sensation in the stomach after 2 hours of eating

Heartburn, fleeting perception of burning sensation in the stomach

Slow digestion, heaviness in the stomach, pain or burning sensation in the stomach immediately after eating

Date

MM

DD

YYYY