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GENERAL INFORMATION SHEET FOR NUTRITIONAL BALANCING - Part 1

NAME:

ADDRESS:

CITY/STATE/ZIP

HOME PHONE:

BUSINESS PHONE:

E-MAIL:

SEX: M F

HEIGHT:

WEIGHT:

HAIR COLOR:

OCCUPATION:

REFERRED BY:

What are your main health concerns or conditions?

Please list any medications or food supplements you are currently taking:

Please list any recent medical tests results you have, such as blood tests:

Please list illnesses in your family such as heart disease, cancer, TB, diabetes or arthritis.

DIET - Part 2

What are examples of typical breakfasts for you? Beverages?

Mid-Morning Snack

What are typical lunches for you? Beverages?

Mid-afternoon Snacks?

What are typical dinners for you? Beverages?

Evening Snacks?

How often and what kind of exercise do you do?

About how many hours of sleep do you get per day?

SYMPTOM CHECKLIST - Part 3

SYMPTOM CHECKLIST - Part 3 Continued

SYMPTOM CHECKLIST - Part 3 Continued

Other symptoms:

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