Frequency and Food Wellness
Confidential New Client Information and Data
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Email *
Name *
Address *
Phone *
Date of Birth *
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Do you have any known allergies? *
Do you have any of the following conditions? *
Required
Do you have any other known conditions? Or would you like to elaborate further on anything checked above? *
Are you currently on any pharma medications? Prescription or over-the-counter? Please list names and the condition for which were given them. *
Have you received vaccinations? If so, which ones and how recently? *
Have you had any surgeries? If so, please elaborate. *
How many times a day are you eliminating, Urine? Feces? Please include pertinent information about any difficulties you experience. *
What is your current quality of sleep like? *
Poor
Excellent
Approximately how many hours of sleep do you get per night? *
Do you wake frequently at night, and have issues going back to sleep? Do you remember your dreams?
What is your current daily energy level? *
Low
High
Describe your daily movement/exercise. *
How would you rate your current eating habits? *
Poor
Excellent
Describe your daily eating habits. *
Are you taking any supplements? If so, what and why?
How would you rate your current stress level? *
Low
High
Do you engage in any activities on a regular basis that are solely for you? (examples may include but are not limited to: mediation/grounding, painting, playing music, yoga, reading, etc.) Please describe. *
Primary concern for your visit today? *
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