Customer Health Assessment Form for Illness Insights | Natural healing without the use of medications. Use herbal remedies, healthy diet, remove chemicals, etc.

Firstname*

Last name*

Your email*

Phone number with international dialing code*

Country*

Your Date of Birth*

Weight in kilograms*

Height in centimeters*

What is you main health problem*

Any other health problems*

What health supplements/herbs do you take*

What medication are you taking*

Do you exercise? Which and how often?*

How much stress are your under?*

A little

Medium

A lot

How often do you eat chocolate?*

Daily

2 or 3 days a week

Almost daily

Never

How many coffee, or caffeinated tea, do you drink daily?*

1 or 2

3 to 5

6 or more

I don't drink coffee

Do you eat organic food at least more than 4 days each week*

Yes

No

How often do you eat fruits?*

Daily several fruits

Daily one fruit

2 or 3 times a week

Rarely

Never

How often do you eat seeds, nuts, avocados, hummus, coconut flesh, milk or other oily products?*

Daily less than 1 ounce

2 to 4 ounces daily

Rarely

Never

I use oil for frying or in saladSingle choice*

Daily

2 to 4 times a week

Rarely

Never

I eat eggs*

Daily

2 or 3 a week

Almost daily

Never

I eat fish or other sea food*

Daily

2 to 4 times a week

Almost daily

Rarely

Never

I eat dairy products (milk, cheese, yoghurt, cream, etc.) from cows, goats, sheep, Ghee, etc.*

Daily

2 or 3 times a week

Almost daily

Never

I eat gluten products such as bread, cakes, biscuits, flour products, pasta or grains (except quinoa, millet and brown rice)*

Daily

Almost daily

Rarely

Never

I eat chicken*

Daily

2 or 3 times a week

Almost daily

Never

I eat beef*

Daily

2 or 3 times a week

Almost daily

Never

Other meat you eat*

I alway check the labels on products I buy to see if they contain chemicals, sugar, etc.*

Yes, always

Now and then only

Never

I smoke*

Yes

No

I drink alcohol*

Daily

2 or 3 times a week

Rarely

Never

IMPORTANT. If you have only recently changed your diet, please state when and explain the changes you made.*

How did you hear about my consultation?*

Word of mouth

Search engines

Facebook

Twitter

Other or cannot remember

A Consultation with Patrick

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