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.: Health Evaluation Form

If you would like a consultation about your health and wellness, please complete this Health Evaluation Form and I will contact you within 3 business days. Required fields are indicated by an asterisk (*). We respect your privacy and do not share your information with outside parties for any purpose whatsoever.

* Your Name

* Email Address

Street Address

City State Zip

Phone Number:

Good time of day to contact you by phone (EST):

Age

Place of Birth

Current weight Weight 6 mo. ago 1 yr. ago

Would you like your weight to be different?

Yes

If so, what?

Relationship status Children?

Occupation Blood Type

How many hours a week do you work?

Do you sleep well?

Yes

Do you wake up at nights?

Yes

What time(s)?

What time do you generally get up in the morning?

Constipation/Diarrhea?

WOMEN:

Are your periods regular?

Yes

How many days is your flow?
How frequent?

Painful or symptomatic?

Yes

Please explain

Do you take any vitamins/medications? If so, which?

Are there any other healers, helpers, pets,
or therapies with which you are involved? Please list

What role does exercise play in your life?

Do you drink coffee, smoke cigarettes,
or have any major addictions?

What percentage of your food is home cooked? %

Where do you get the rest from?

How is the health of your father?

How is the health of your mother?

Serious illness / hospitalizations / injury?

What is your chief health concern?

What's your food like these days?

breakfast

lunch

dinner

snacks

liquids


	Tom Donofrio, Family Nutrition Expert.com, 112 Drakewood Place, Cary, NC 27518 Tel 919-413-6481 ·