| First Name: | |
| Last Name: | |
| Date: | |
| Referred By: | |
| Blood Type: | |
| Birth Date: | |
| E-mail: | |
| Full Address: | |
| Telephone: | |
| Place of Work: | |
| Work Phone: | |
| Cell: | |
| Height: | |
| Previous Diets: | |
| Do you have a stressful lifestyle? If so, explain. | |
| How is your energy level? 10 is best, 1 is worst: |
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| Do you exercise? What kind and how often? | |
| Do you drink? |
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| Have you quit drinking? When? | |
| Do you smoke? |
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| Have you quit smoking? When? | |
| Current Supplements: | |
| Current Medication: | |
| Medical History and Surgeries: | |
| Have you use antibiotics in the last 6 months? |
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| Reason for Appointment: | |
| Favorite Food: | |
| Least favorite Food: | |
| Current Diet - Breakfast: | |
| Current Diet - Lunch: | |
| Current Diet - Dinner: | |
| Current Diet - Snacks | |
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