Name *
Name
Gender
Birthday
Birthday
Address
Address
Cell
Cell
Health and Wellness Goals
Please list at least 3
How have you dealt with your main areas for Concern in the past?
Are you currently working any any other health practitioners?
1 being not very adherent, 10 being very adherent
1 not very much, 10 very much so
Health History
Please check any that apply to your medical history:
Women’s Health
Do you have regular Periods?
Do you experience any PMS Symptoms?
Are you taking Birth Control?
Have you had Menopause?
Men's Health
Do you erectile concerns?
Do you have prostate concerns?
Medications & Supplements
Name, Duration, Dosage and For What Reason
Date, Description
Stress
What is your current stress level?
Digestion
Describe your bowel movements:
Do you suffer from any of the following:
Nutrition & Lifestyle
Are you currently following a restricted diet?
Do you drink coffee?
Do you eat breakfast?
Do you drink alcohol?
Do you smoke (cigarettes, recreational drugs, cigar)?
Are you familiar with how to read and understand food labels?
Do you often feel hungry?
What foods do you typically crave?
Which of the following foods do you consume regularly?
Indicate all that apply to your current state of being, lifestyle and eating habits.
Informed Consent
Nutrition and exercise are intended to promote general health and wellness and are not intended to replace medical care. All nutritional assessment, suggestions and consultation on nutrition, diet and exercise are based on your input and are not intended to diagnose, treat or cure any disease or ailment. Results and changes in your general health and wellness may vary depending on medical conditions, medications and accuracy in the following suggested guidelines. Never reduce or eliminate physician prescribed medications without the direction of a medical care provider. I confirm that all the information I have given is true and to the best of my knowledge. I understand that Jen Segger (as Challenge by Choice Training Systems, JLS Training Systems Inc) is not a registered dietician and can only help guide you as it relates to overall health and wellness.
Signature
Signature
Date
Date