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Kingston, ON
613-888-4871
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Home
About Us
About Us
Contact
Cleanses
Menu
Shop
Wholesale
Holistic Nutrition
Nutrition Consultations
Metabolic Detoxification Questionnaire
Consultation In-Take Form
Wellness Delivered
Nutrition Consultations
In-Take Form
Personal Information
Name
*
Name
First Name
Last Name
Date Of Birth
Date Of Birth
MM
DD
YYYY
Email Address
*
Phone
*
Phone
(###)
###
####
Address:
*
Gender
Male
Female
Reffered By:
Blood Type:
A
B
AB
O
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Yes
List paternal and maternal family diseases:
Do you have pets?
Yes
No
If you answered 'yes' to having pets, what kind?
I- What type of cardio/weight exercise do you do? II- How often & duration?
Do you experience digestive difficulties? (i.e. bloating, constipation, gas, etc.)
Yes
No
If you answered 'yes' to the above question, please describe.
Do you have a bowel movement everyday? How often?
List any food and environmental allergies you have:
Is there anything that will get in the way of following a treatment plan in order to achieve results?
Do you experience any of the following? Rate from ‘0’ = Never ‘1’= Mild ‘2’= Moderate ‘3’= Severe
General Fatigue or weakness:
0
1
2
3
Frequent Infections/Illness:
0
1
2
3
Depressed or irritable:
0
1
2
3
Insomnia/restless sleep:
0
1
2
3
Muscle cramps:
0
1
2
3
PMS:
(Female)
0
1
2
3
Hot Flashes:
(Female)
0
1
2
3
Frequent Yeast/Fungus:
0
1
2
3
Cellulite
0
1
2
3
Excessive Mucous/ sinus discharge:
0
1
2
3
Arthritis/ joint/back pain:
0
1
2
3
Low sex drive:
0
1
2
3
Headache/Migraines
0
1
2
3
Health History
Have you ever been hospitalized for a surgery? For What? Approximately when?
List all supplementation (vitamins, minerals, herbs) you are taking:
List all prescription medication you are taking and why you are taking it:
Describe any health issues/problems you are currently experiencing. Specify your main concern:
DIET
Please list sample daily diet
Upon Rising/Breakfast:
Lunch:
Dinner:
Snacks:
Alcohol (How much & how often):
Coffee/Black Tea (How many per day):
Carbonated Beverages (How many per day):
How many glasses of water do you drink per day?
What is your source of drinking water?
Filtered
Tap
Reverse Osmosis
Bottled
How much fruit do you eat in a day?
How many vegetables do you eat per day?
What type of fat/oil do you cook with/consume?
Do you regularly consume dairy?
Yes
No
Do you consume/crave sugary foods, candy, pastries?
Difficulty digesting certain foods?
Provide any other information that may be relevant, but hasn’t been covered in regard to diet.
Emotions
Is your occupation stressful?
Yes
No
Are there any stressful relationships with family members/friends?
Yes
No
Provide any other information that may be relevant, but hasn’t been covered in regard to emotions.
Occupation:
How many cigarettes do you smoke per day?
For how many years?
If you quit, how long ago?
How many metal dental fillings do you have?
Have you had any removed? If 'yes' how many & approximate date of removal?
How many root canals do you have?
Date of most recent root canal:
Date of most recent root canal:
MM
DD
YYYY
Do you use antacids? How often?
Have you ever been on antibiotics?
Yes
No
If you selected 'yes,' please indicate how often.
Do you use chemical perfumes such as air fresheners, scented candles, skin care products or plug in air fresheners?
Yes
No
Thank you!
