Client Questionnaire Part 1 First Name * Last Name * Email * Phone 1 * Metabolic Blood Sugar Problems * Nothing Intermittent Chronic (Medication prescribed) Blood Pressure Concerns * None Intermittent Chronic (Medication prescribed) Edema (Fluid Retention) * None Intermittent Chronic (Medication Prescribed) Fatigue * None Intermittent Chronic (Medication Prescribed) High Cholesterol * None Intermittent Chronic (Medication Prescribed) Weight Gain (5-10kg) * Yes No Obesity (over 10kg) * Yes No Digestive Bloating * None Intermittent Chronic Candida (Thrush Infection) * Never Intermittently Chronic (Regularly) Celiac Disease * Yes No Crohn's Disease * Yes No Colitis * Yes No Constipation * None Intermittent Chronic Diverticulitis * None Intermittent Chronic Gas * Not much A lot Chronic Hemorrhoids * None Intermittent Chronic Indigestion * None Intermittent Chronic Irritable bowel * None Intermittent Chronic Lazy bowel * None Intermittent Chronic Parasites * None Intermittently Chronic Stomach or peptic ulcers * None Intermittent Chronic (Medication Prescribed) Acid Gall Stones * None Intermittent Chronic Gout * None Intermittent Chronic Heartburn * None Intermittent Chronic (Medication Prescribed) Kidney Stones * None Intermittent Chronic Reflux * None Intermittent Chronic (Medication Prescribed) Skin Acne * None Intermittent Chronic (Medication Prescribed) Boils * None Intermittent Chronic Eczema * None Intermittent Chronic Psoriasis * None Intermittent Chronic Inflammation Allergies * None Intermittent Chronic What are you allergic to? Arthritis * None Intermittent Chronic (Medication Prescribed) Asthma * None Intermittent Chronic (Medication Prescribed) Dry Cough * None Intermittent Chronic Mucus congestion * None Intermittent Chronic Sinusitis * None Intermittent Chronic Nervous Depression * None Intermittent Chronic (Medication Prescribed) Headaches * None Intermittent Chronic (Medication Prescribed) Insomnia * None Intermittent Chronic (Medication Prescribed) Memory Loss * None Intermittent Chronic Palpitations * None Intermittent Chronic Stress * None Intermittent Chronic (Ongoing) Submit Part One
