Luke’s Initial Info Form Page

Name
D.O.B
Age
Sex M/F
Date
City
Address
County / State / Province
Post Code
Country
Home Phone
Business Phone
Email
Height
Weight
Occupation
How were you referred?
What are your main health concerns or conditions?
Please list any medications or food supplements you are currently taking:
Please list any recent medical test results you have, such as blood tests:
Any past surgeries and dates:
Please list illness in your family such as heart disease, cancer, TB, diabetes, arthritis etc.
DIET: What are examples of typical breakfasts for you?
Beverages
Mid-morning Snacks:
What are typical lunches for you?
Beverages
Mid-afternoon Snacks:
What are typical dinners for you?
Beverages
Evening Snacks:
How often and what exercise do you do?
About how many hours of sleep do you get per day?
Alcohol use: Type / Ounces / How Often
Tobacco: Type / How Often
Recreational Drug use: Type / How Often
I understand that Nutritional Balancing is a means to reduce stress and balance body chemistry. It is not intended as diagnosis, treatment or prescription for any condition or disease
- Yes
- No