Lifestyle for Health 993 Greenland Forest Drive Monument, CO
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1 Lifestyle for Health 993 Greenland Forest Drive Monument, CO Initial Health Consultation New Client Form and Release Form Please complete these forms prior to your appointment and bring them with you to your appointment. Also bring all supplements that you are currently taking. Scores from 3 questionnaires will need to be added to this form (Metabolic Profile, Candida, Enzymes). These questionnaires can be found on our website: under the Coaching Tab and then Questionnaires (the same page where you found this form). If you are not coming into the office for your appointment (long distance clients), you will mail this form to the above address along with: Your Hair Sample (in a baggie with your name on the bag - enough hair to cover the face of a quarter) Samples of all supplements you are currently taking - one pill or capsule of each, in an individual baggie with the product name written on it. Your Blood Type: (O, A, B, AB) also goes on this form (if not known, you can order a Blood Type Test Kit from Amazon - usually less than $10). This is not required but is helpful. Name Date Daytime Phone Age _ M / F Weight _ Height Address City / ST / Zip Profession Referred by Fee: $295 Pay by Check Pay by Credit card Blood Type O A B AB (circle one) Metabolic Profile (circle one) Candida Score
2 Give a score to each of the following with 1 being low/none and10 high/more than enough: Energy Pain Where/Frequency: Headaches Frequency: Job Stress Family Stress # Bowels/Day Lasik Eye Surgery: Y / N Mono-Vision Surgery: Y / N Mono-Vision Contacts: Y / N Glasses: Single Vision: Y / N Bifocal: Y / N Trifocal: Y / N Breast Implants Y / N Root Canals Y / N Number of root canals: Silver Dental Fillings Y / N Other Dental Issues: Amount of water consumed/day: Typical Breakfast: _ Average Dinner and Dinner Time: Foods craved, even you you don t regularly eat them: Sleep - average # hours slept each night: Quality of Sleep: Other:
3 Top Scores from the Enzyme Questionnaire: (example: Group 12 score of 10 ) Group _ Score Group Score Group Score Group _ Score Group Score Group Score Group _ Score Group Score Group Score Group _ Score Group Score Group Score Please provide a brief health history, including surgeries, dental, accidents, broken bones and trauma: What supplements do you currently take (Bring with you to your appointment):
4 What is your #1 desired outcome from you appointment? When you achieve that outcome, how will your life be different? Where do you tend to sabotage yourself? Other:
5 Lifestyle for Health 993 Greenland Forest Drive Monument, CO Release Form (Disclosure Statement require under SB-215 for Alternative Health Care Practitioners in Colorado As an Alternative Health Care Practitioner, I am not licensed to provide medical treatment, diagnose disease or prescribe medications. The services I perform in person, by mail or by phone are restricted to nutrition and lifestyle choices and the maintenance of nutritional health. I provide services in the areas of Naturopathy, Enzyme Nutrition, Herbology, Nutrition, Diet, Homeopathy, Stress Management, Low Level Light/Laser Therapy and Quantum BioFeedback. I do not carry liability insurance applicable to any injury caused by an act or omission in providing complementary and alternative health care services. A copy of this disclosure statement will be kept on file for at least two years after the last date of service. My Professional degrees, training, certifications include: * Naturopathy Doctor from Trinity College * Digestive Health Specialist from Loomis Institute * Bioenergetic Practitioner II and Wellness Consultant from The International Academy of Bionetic Practitioners * BA, Home Economics and Nutrition Education from Washburn University, Topeka, KS * BBA in Business Management and Computer Science from Washburn University, Topeka KS * Authored 15+ books, appeared on 1,000+ media shows * Worked with tens of thousands of people from around the world Name of Client Signature Address City, State, Zip Phone # Address In order to treat a child between the age of 2-18 years of age, a legal guardian/parent must sign Name of Child (age 2-18) Signature of Parent/Legal Guardian
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