Please note: āDā denotes Doctor opinion required.
First Name
Last Name
Email
*
Who is your regular Dr/health professional?
*
What is your Dr's/health professional's address?
*
Any food intolerances/allergies?
*
Yes
No
Details
Any food restrictions?
*
Yes
No
Details
At home, who prepares the food?
*
Are you prone to constipation?
*
Yes
No
Details
Do you sleep well?
*
Yes
No
Details
Are you currently being treated for cancer? (D)
*
Yes
No
Details
Have you ever suffered from anorexia or bulimia? (D)
*
Yes
No
If so, when?
Have you ever suffered from kidney or liver failure? (D)
*
Yes
No
Details
What medications (prescription or natural) or nutritional supplements do you take? Please list medications name and what it's for.
Do any of the following apply to you:
*
Any heart condition or disease?
Under 15 years of age (Planner 3)
Kidney stones (Planner 3)
Gout (Planner 3)
Gall stones (Planner 3)
None
Have you had high blood glucose? (D)
*
Yes
No
Have you had high blood glucose? (D)
*
Details
Do you have diabetes
*
Yes
No
If yes, how is it controlled?
With food and exercise alone
With oral medication (Planner 3) (D)
With insulin (Planner 3) (D)
Females only
Do you have Polycystic Ovary Syndrome?
Are you pregnant or breast feeding? (D)
Do you have an underactive thyroid?
*
Yes
No
. Do you have any other conditions that may restrict your ability to participate in a healthy eating program?
*
Yes
No
Details
Signature
*
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