Health profile

We would like to help you. Please complete the form below as best you can.

CONTACT INFORMATION
(all fields in bold are required)

First Name
Last Name
Email
Phone
Street address
State Zip/Postal Code
Age Gender Male Female
Reason for contacting Food Beautiful:


Would you like us to contact you? Yes No

HEALTH INFORMATION
(all fields in bold are required)

1. Have you ever been diagnosed with a disease? If yes, please specify:


2. Personal stress level: (0=lowest , 10=max)
3. Is your stress from work or other?

4. Do you suffer from anxiety?  Yes No
5. List any surgeries you have had:

6. Have you had any organs removed?
7. List your prescribed drugs and purpose for taking them:

8. Have you had the flu vaccine?  Yes No
9. What types of vaccinations have you had in the last 5 years?

10. Have you had side effects from the vaccinations?

11. If you have allergies, list types of allergies that you have:

12. Number of bowel movements a day:
13. Do you exercise?  Yes No
List type and duration of exercise:

14. Do you get outside in the sun at least 3 times a week?
 Yes No
15. How many ounces of water you consume in a day?
16. Current weight: Desired weight:
17. List any vitamins and herbs you may be taking:

Please select every item below that applies to you:

 Nail or Foot Fungus Dry Skin Oily Skin Dandruff Adult Acne Eczema  Psoriasis Get cold soars High Cholesterol High Blood Pressure High Triglycerides Diabetes Hypoglycemic Migraines Overweight Low Sex Drive Yeast Infections Kidney Stones Gallstones Pain in stomach Pain in below right rib Pre- Menopause Menopause No Menstruation Anemia Hypothyroid Heavy Menstrual Cycle Hysterectomy Birth Control Frequently Sick Smoke Drink Alcohol Drink Pop Drink Coffee Drink Black Tea  Depressed Crave Sweet Foods Crave Salty Foods Hungry most of the time Indigestion after eating Gas after meals Acid Reflux Muscle cramps day Muscle cramps at night Cold hands Injuries slow to heal Tendonitis / Joint Pain Arthritic pain Fibromyalgia Osteoporosis / Osteoarthritis Stiff upon arising Wake up groggy Wake up with Puffy Eyes Slow rising in morning Swollen joints Swelling in Legs Loose stool Constipation Foggy minded Tired all day long Mood swings Angry  Quiet Quiet voice Loud Voice Emotional eater Competitive In a relationship with boyfriend or married In a healthy relationship

DIETARY HABITS
(all fields in bold are required)

List what you typically eat and the portion size during a two day period:


1. What do you eat for breakfast?

2. What do you eat for lunch?

3. What do you eat for dinner? What Time?

4. What do you eat for snacks?

5. Do you eat fruit every day?  Yes No
How much fruit do you eat in a day?
6. Do you eat vegetables every day?  Yes No
What types of vegetables do you eat?

7. Do you eat sweets every day?  Yes No
What types of sweets do you eat?

8. Do you have any food allergies?  Yes No
If yes, please list them:

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