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.
For the following questions, please check the phrases that apply to you:
How are you bowel eliminations?
How many hours do you spend daily with the following devices:
Personal Care Products
Please check each type of food that you eat often (once a week or more):
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 brand and how it was prepared "baked organic chicken". Instead of writing "salad", identify what it was made of, such as "salad made with organic baby green lettuce, commercial cherry tomatoes and PRL olive oil".) PLEASE BE HONEST!
Electrical Devices Worn on Body
Toxic Body Exposure
Personal Health Goals