NEW Client General Information Form Name * First Name Last Name Address * City * State * Zip Code * Country * Phone (including area code) * Email Address * Sex Male Female Age * Height * Weight * How were you referred: * Internet Search Friend/Family Other Referral (if applicable) Occupation * What are your main health concerns or conditions? * Please list any medications you are currently taking: * Please list any supplements you are currently taking: * Please list any recent medical tests you have, such as blood tests: * Please list illnesses in your family such as heart disease, cancer, TB, diabetes, or arthritis etc: * DIET: What are examples of typical breakfasts for you: * Mid-Morning Snacks (if applicable): What are typical lunches for you: * Afternoon Snacks (if applicable): What are typical dinners for you: * Evening Snacks (if applicable): How often and what type of exercise(s) do you do: * What time do you go to bed and how many hours of sleep do you average each night: * (Optional): Have you received the Covid Vaccine(s)? If yes please complete the next section. Option 1 Option 2 (Optional): Which Covid vaccine(s) did you receive? (Optional): Dates you received the Covid vaccine(s): Symptoms Page Check all symptoms that presently describe you: Joint Pain Joint Stiffness Arthritis, Osteo Arthritis, Rheumatoid Muscle Pain Muscle Weakness Muscle Cramps Bursitis Fractures Osteoporosis Gout Sweet Cravings Sugar Reactions Irritable Before Meals Can't Skip Meals Hypoglycemia Crave Starches Fat Cravings Other Food Cravings Food Allergies Excessive Hunger No Hunger Diabetes Rapid Heart Rate Skipped Heart Beats Heart Palpitations Heart Attack Poor Circulation Dizziness Low Blood Pressure High Blood Pressure Angina Arteriosclerosis High Cholesterol High Triglycerides Cough Bronchitis Asthma Post Nasal Drip Sinus Congestion Allergies Emphysema Fatigue Hypothyroidism Low Body Temperature Cold in Winter/Dry Skin Tendency to Gain Weight Hyperthyroidism Eye Conditions Acne Eczema Fungal Infections/Candida Psoriasis Hives Hair Loss Slow Wound Healing Cataracts Glaucoma Menjere's Disease Tooth Decay Excessive Plaque on Teeth Gum Disease Infections/Viruses Epstein-Barr Virus Tumors/Cancer Multiple Sclerosis Parkinson's Disease Scleroderma Fear Anger Anxiety Bipolar Disorder Brain Fog Confusion Depression Irritability Mind Races Mood Swings Obsessive/Compulsive Panic Attacks Poor Memory Suicidal Thoughts Schizophrenia Trouble Sleeping/Insomnia Autism Attention Deficit Hyperkinesis Dyslexia Seizures Learning Disability Mental Retardation Delayed Development Bladder Infections Kidney Infections Trouble Urinating Frequent Urination Painful Urination Kidney Stones Water Retention Sinus Headaches Tension Headaches Migraines Headaches Neuritis Constipation Diarrhea Intestinal Gas Bloating Heartburn Ulcer Stomach Pain Colitis Gall Stones Fissures Hemorrhoids Cirrhosis Diverticulitis Tendency to Lose Weight Anemia Easy Bruising Dental Amalgams Abuse Drug Addiction Alcoholism Smoking WOMEN: Premenstrual Syndrome Water Retention Cramps No Menstruation Heavy Periods Light Periods Irregular Periods Ovarian Cysts Fibroid Tumors Abnormal Pap Smear Menopause Fibrocystic Breasts Breasts Tumors Yeast Infections Hot Flashes MEN: Prostate Problems Impotence Infertility Other Symptoms Please list any other symptoms you have, including eye conditions: Most Important Symptoms Please list the symptoms that are the most important to you: Additional Information You would like to share: Please sign the waiver in the box below: * I understand that nutritional balancing is a means to reduce stress and balance body chemistry. It is not intended as diagnosis, treatment or prescription for any condition or disease. All recommendations for supplements, products, or procedures, are not intended as treatment or prescription for any disease or as a substitute for medical care. All handouts or information dispersed during individual appointments or at workshops are the opinions of Doreen McCafferty, Nutrition and Lifestyle Consultant, unless otherwise noted. Individual articles are based upon the opinions of the respective author, who retains copyright as marked. This information is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information from the research and experience of Doreen McCafferty and her community. Doreen McCafferty encourages you to make your own health care decisions based upon your research and in partnership with a qualified health care professional. Date * MM DD YYYY Thank you!
