Health Form

Health Questionnaire Form

Please complete and submit this form. We look forward to hearing from you. Thank you

Name*
FirstLast
Email
Enter EmailConfirm Email
Cell phone
(###)###-####
Birth date
MM
DD
YYYY
Place of birth
Current Weight
Weight 6 months ago
Weight 1 year ago
Occupation
Time you go to bed
: HH
MM
Morning wake up time
: HH
MM
Constipation / Diarrhea
Under a medical doctor or therapists care
Conditions
Do you take and vitimins/ medications? If so, what?
Impending surgeries
Daily/weekly exercise routine:
Blood type
Other information you'd like me to know:
Do you drink coffee/ tea/ soda/? Amount per day...
Cigarettes per day...
Alcohol consumption per week, number of drinks per week.
Do you have any pain, if yes, where?
How much of your food intake is home cooked? Where do you get the remainder from?
Cravings provide important information about deficiencies: List foods you crave and eat on a regular basis:
List 'Outliers'-those foods in which you try not to eat but occasionally indulge:
Please list typical and atypical intake of food for breakfast. Specify brand names. (i.e Kashi, Purdue turkey, Pacific tomato soup...))
Please list typical and atypical intake of food for lunch. Specify brand names again.
Please list typical and atypical intake of food for dinner. Specify brand names again.
Please list snacks you consume daily.
Do you have allergies to foods? List all: Other allergies?
Referred by...
What concerns do you have regarding your health?
Signature
For legal reasons, please read and sign the following: I am seeking this information and/or participating in a cleanse program for my personal growth. I take full responsibility for my health and decisions I make during and following this non-medical program and any future consultations. I hereby discharge Nourishing Habits LLC and Karen (Kai) Hersher from any and all claims that I or my family or heirs, have or may have, now or in the future. I have read and understood all of the above and agree to proceed under these conditions. I understand that this paragraph is meant to have legal significance and that all of the above statements are true. If you agree, please sign here

Hit the submit button and make certain you have filled in the required fields in the Health Form. You will be notified your submission is complete. Thank you

* Alternatively please print and complete Health Questionnaire Form PDF and deliver to Kai.

Health Questionnaire Form

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