Client Consultation Form
Name_____________________________________________
DOB___________________________________________________
Weight______________________
Why are you seeking my help today?___________________________________________________________________
___________________________________________________________________
Do you have any family history of disease? E.g. Cancer, High blood pressure or Diabetes.______________________________________________________________
Do you sleep well at night?_____________________________________
Do you get up to use the bathroom at night?______________
Do you move your bowels on a regular basis________How often?___________
Circle the answer that is closest to what you see:
What color is it? Yellow, light brown, dark brown, almost black
What color is your urine? Clear, almost clear, slightly clear, yellow, dark yellow almost orange.
Do you have any food cravings? ________ What kind of food do you most frequently crave?_______________________________________________________________________________
When do you have these cravings?_________________________________________________
Do you ever suffer from indigestion? ______If yes, when you eat what foods?_______________________________________________________________________________
How much water do you drink daily?______________________________
Do you drink juice or soda?________How much daily?________________
What does a typical breakfast, lunch and dinner consist of for you?_________________________________________________________
Do you exercise? __________How often?______________________________________
_________________________________________________________________________
Do you have any known allergies?____________________________________________
________________________________________________________________________
Do you suffer from fatigue?______________
