General Information Form

Name*
First Last
D.O.B*
Age*
Sex M/F*
Date
City*
Address*
County / State / Province*
Post/Zip Code*
Country*
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

Please fill out the section below concisely and write exactly what foods you are eating. Please do not skip this and just write 'slow diet', 'nb diet' or 'veggies and protein'. It is important for us to know what you are eating so we can properly help. Thankyou!
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

DIET