Follow-up Evaluation

Please complete the following questions carefully. This information will help us to build a specialized nutritional program, personally designed for you.
All information listed will remain confidential between client and health coach.

Personal Information

Health Challenge(s)
Other Information
Medications
Stress Level
Dental Work
New Stress

Health Overview

For the following questions, please reply with a short answer.

Sleep
Digestion
Urination
Bowels
Women Only
Exercise
Sunlight

Nutritional Progress

Food Choices

Please check each type of food you have often consumed in the last 30 days

Food Habits

Eating Out
Home Meals
Meal Habits
MSG
Water

Typical Diet

Please fill out your typical diet for the last few weeks. Please be as detailed as possible (for example, instead of writing "chicken", identify what type and how it was made such as "baked organic chicken". Instead of writing "salad", identify what it's made of, such as "salad made with organic baby green lettuce, commercial cherry tomatoes and PRL olive oil"). Please, be honest!

Additional Information