LIFE STYLE ANALYSIS
PRIVATE CONSULTATION
                                                  

Please answer all relevant questions.
You understand that our counseling cannot and should not replace the advice of a medical doctor and that any medical condition must be treated by a licensed physician.

1. Personal Information (Confidential)

First Name*:
Last Name*:
Date of Birth*:
(mm/dd/yyyy)
Gender*
Street*
City*
State*
Zip Code*
Telephone Number*:
Your E-Mail Address*:
Weight*:
Lbs.
Height*:
Ft.
Blood Type:
Marital status
 
Number of children
Kindly referred by:
Please give us this person's full name
List all surgeries and approximate dates: (Root canals, dental works included)
 
Explain your type of work
 

2. Diet and Nutrition

a) How often do you eat the following?
Red Meat
Wheat (White or Whole)
Sweets and sugars
Sodas
Coffee. Teas, Cokes (diet or not)
Salt or Salted Foods
Dairy Foods
Alcohol (including wine)
Poultry
Nutrasweet (sweetners)
Pork
Vegetables
Fish Fast food
Fried Foods & Cooked fats Fruit

b) More about your eating habits

Describe a typical Breakfast
Describe a typical lunch
Describe a typical dinner
What kind of water do you drink and HOW MUCH of it a day (cups)?
List all nutritional supplements you are taking
List all medications you are taking
3. General Health Practices

1. How much sleep do you get each night on the average?

2. Do you exercise? How much?

3. Do you feel that you are under stress? If so, briefly explain.

4. How often does your bowel eliminates?

5. Please list your current health concern

4. A System Approach to Natural Health

Click or check the box preceding a question, ONLY IF that particular condition
applies to you, if it does not, move to the next question.
  • General Weakness or lethargy
  • Frequent illness
  • Body odor and/or bad breath
  • Difficulty in digesting certain foods
  • Frequent consumption of red meat
  • Periodic female concerns
  • Frequent use of antibiotics
  • Heavy Alcohol consumption
  • Frequent mood swings
  • Food allergies
  • Bags under eyes
  • Smoking
  • Poor concentration and/or poor memory
  • Poor resistance to disease
  • Belching or burping after meals
  • Traumatic lifestyle
  • Skin/complexion problems
  • Cravings for sweets and/or processed foods
  • Regular consumption of dairy products
         (milk, cheese,cream, butter, ice cream)
  • Feeling low, uninterested, angry
  • Too little sleep or restless sleep
  • Easily broken fingernails
  • Hair with split ends
  • High fat diet
  • Unsettled, apprehensive, pressured
  • Low fiber diet (Not enough fruits)
  • Muscle cramps
  • Exposure to air pollution
  • Sleepiness when sitting
  • Cokes, Sodas, Caffeine consumption
  • Feeling out of control
  • Food/Chemical sensitivities
  • Problems with yeast/fungus
  • Structural weakness
  • Excessive worry
  • Easily irritated
  • Too little exercise
  • Excessive mucus

 

Disclaimer:
We do not directly dispense medical advice or prescribe the use of herbs or supplements as a form of treatment for illness.
The information found on this Web Site is for educational purposes only to empower people with knowledge to take care of their own health. We disclaim any liability if the reader uses or prescribes any remedies, natural or otherwise, for him/herself or another.
Historically all of these herbs & vitamin supplements may nutritionally support the bodies biological systems.
Please consult a health professional should a need be indicated.