Name
Email
Phone
SOME BASIC QUESTIONS ABOUT YOUR METABOLISM
Any blood sugar issues
None Type 2 diabetes Type 1 diabetes Blood Pressure
Normal Has been high on occasion High Blood pressure (medicated) Fluid Retention
None Intermittent Chronic Fatigue
None Intermittent Chronic Cholesterol Levels
Normal A little elevated I'm on medication for this Body Weight
Underweight Ideal 5-10kg Overweight 10-15kg Overweight 15kg or More Overweight Do you suffer with Kidney Stones? Do you suffer with Gall Stones? SOME BASIC QUESTIONS ABOUT YOUR DIGESTION
Do you suffer with Indigestion Do you suffer with Acid Reflux (Heartburn)? Do you suffer with Constipation Do you suffer with Bloating? Do you suffer with Gas (wind)? Do you suffer with Candida (or Thrush)? Do you suffer with Irritable Bowel Syndrome? Do you suffer with Celiac Disease? Do you suffer with Crohn's Disease? Do you suffer with Parasites? Do you suffer with Stomach Ulcers? A COUPLE OF QUESTIONS ABOUT YOUR SKIN
Do you suffer with Excema? Do you suffer with Psoriasis? Do you suffer with Boils? Any other skin condition you want to describe?
JUST A COUPLE OF BASIC QUESTIONS ABOUT IMMUNITY AND INFLAMMATION
Do you suffer with any Allergies? (if so please list)
Do you suffer with Arthritis? Do you suffer with Asthma? Do you suffer with a sinus congestion? Do you suffer with a lung congestion? Do you suffer with a cough? Any other immune disorder you can describe?
SOME QUICK QUESTIONS ABOUT YOUR STRESS LEVELS
Do you suffer with Headaches? Do you suffer with Insomnia? Do you suffer with Depression? Do you suffer with Confusion or Memory loss? Do you suffer with Palpitations? How would you rate your stress levels?
A QUICK CHECK ON YOUR DIET HABITS
HOW OFTEN DO YOU EAT THESE ITEMS?
Alcohol
Never Occasionally Regularly Addicted Tobacco (or Vape)
Never Occasionally Regularly Addicted Beef & Lamb (red meat)
Never Occasionally Regularly Addicted Burgers or Fish 'n Chips
Never Occasionally Regularly Addicted Bread, Pastry, Cake (Baked goods)
Never Occasionally Regularly Addicted Cheddar Cheese
Never Occasionally Regularly Addicted Chocolate or other sweets
Never Occasionally Regularly Addicted Standard Coffee or Tea
Never Occasionally Regularly Addicted Energy Drinks
Never Occasionally Regularly Addicted Other sugary drinks
Never Occasionally Regularly Addicted Ice Cream or other desserts
Never Occasionally Regularly Addicted Margarine
Never Occasionally Regularly Nuts
Never Occasionally Regularly Addicted Seeds
Never Occasionally Regularly Addicted Potato chips
Never Occasionally Regularly Addicted Any other junk food you want to mention?
WHAT MEDICATIONS YOU ARE TAKING?
Please list any prescription drugs you are taking
Please list any supplements or herbs you are taking
Please list any other recreational drugs you are taking (this is kept confidential)
A COUPLE OF LIFESTYLE QUESTIONS
How often do you go walking?
Everyday Once or twice a week Once or twice a month Never How often do you go running?
Everyday Once or twice a week Once or twice a month Never How often do you do garden work?
Everyday Once or twice a week Once or twice a month Never How often do you do a gym workout?
Everyday Once or twice a week Once or twice a month Never Do you have a physical job?
No, I have a desk job? Yes, I move around in my job? I have a hard physical job? How often do you participate in sports?
Everyday Once or twice a week Once or twice a month Never ADD ANY EXTRA DETAILS ABOUT YOUR GOALS
Outline any other specific details of your health concern
What's your number one priority with this consultation?
Send