Client Information Form

Name *

Gender *

Phone Number *

Email *

City *

Age *

Height in Feet/Inches *

Weight in Kgs *

How did you hear about me? *

What are your health goals/health concerns? *

Are you under any other kind of therapy or treatment? *

Are you taking any medication/supplements currently or in the past? *

Past History

Any major past health problems or surgeries? *

Any major allergies or food aggravations? *

Any emergency treatments that you have needed in the past? Please specify *

Any hospitalization needed in the past? For what condition? *

Do you do any exercise regularly? *

Do you have any major stress? *

Family History

Is there a family history of any of these conditions? If yes, please describe *

Daily Schedule

Describe in brief the nature of your work and your work/ home schedule (time you start and finish etc.) *

How are your Bowel Movements (regular/ everyday smooth?, irregular? constipated/ or need stimulation such as tea or coffee to be able to eliminate?) *

Usual waking up time *

Sleep time *

Describe what you usually eat for:

Breakfast *

Mid Morning *

Lunch *

Afternoon *

Evening *

Dinner *

Post Dinner *

Do you consume tea/ coffee? How many cups in a day? *

Do you consume alcohol? How much and how often? *

Do you smoke? How many in a day? *

Upload Reports *

Click or drag files to this area to upload. You can upload up to 8 files.