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Home
About
Services
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Urgent Session
Shop
SHOP BY CATEGORY
Books
Extracts
Formulas
Skincare
Superfoods
Vitamins
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SHOP BY CONDITION
Antioxidants
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Healthy Aging
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Menu
Home
About
Services
Consultations & Packages
Urgent Session
Shop
SHOP BY CATEGORY
Books
Extracts
Formulas
Skincare
Superfoods
Vitamins
Water Filtration
Affiliate Product Recommendations
Fullscript Products
SHOP BY CONDITION
Antioxidants
Energy & Fitness
Foundational Wellness
Hair, Skin & Nails
Healthy Aging
Immune
Joint & Bone
Liver & Digestion
Memberships
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CLIENT QUESTIONNAIRE & DISCLAIMER
Name
(Required)
DOB
(Required)
MM slash DD slash YYYY
Age
Place of Birth
Phone
(Required)
Email
(Required)
Referred By
Address
City
State
Zip
Height
Weight
Health Concern & Goals
Clinical Diagnosis
Headaches
Yes
No
Headaches How often
Migraines
Yes
No
Migraines How often
Section Break
Digestive Problems
Yes
No
Diarrhea
Yes
No
Constipation
Yes
No
Gas after eating
Yes
No
Section Break
Acid reflux
Yes
No
Insomnia
Yes
No
Bowel movements per day
Urination at night
Yes
No
Section Break
Adult acne
Yes
No
Eczema
Yes
No
Eczema # Years
Dandruff /Flaky Scalp
Yes
No
Section Break
Arthritis
Yes
No
Arthritis How many years
Joint Pain
Yes
No
Joint Pain Where
Section Break
Poor Concentration
Yes
No
Ringing in ears
Yes
No
Level of Stress 1-10 (10 is max)
Known Food Allergies
Section Break
Low Back pain
Yes
No
Upper Back Pain
Yes
No
Hormone Imbalance
Yes
No
Painful Menstruation
Yes
No
Section Break
Hypothyroidism
Yes
No
Low Sexual Drive
Yes
No
Eat sweets daily
Yes
No
Sweets Type
Section Break
Drink Soda
Yes
No
Number of Soda Drinks Per Day
Section Break
Drink Alcohol
Yes
No
Number of Alcohol Drinks Per Day
Water in oz. per day
Section Break
Drink Tea
Black
Green
Herbal
Drink Coffee
Yes
No
Cups of Coffee Per Day
Section Break
Drink Juice
Yes
No
Chew Gum
Yes
No
Smoke
Yes
No
Use Marijuana
Yes
No
Section Break
Take Recreational Drugs
Yes
No
History of Cancer
Yes
No
History of Heart Disease
Yes
No
Family History
Recent Vaccinations
Previous Injuries/Surgeries & When
Vitamins & Brand Taking Daily
Prescription Drugs Current
DIETARY HABITS
Write down a two day food diary or your typically eating patterns.
What do you eat for Breakfast? (please provide serving size) and time
Breakfast Day 1
Breakfast Day 2
What do you eat for Lunch? (please provide serving size) and time.
Lunch Day 1
Lunch Day 2
What do you eat for Snacks? (please provide serving size) and time.
Snacks Day 1
Snacks Day 2
What do you eat for Dinner? (please provide serving size) and time.
Dinner Day 1
Dinner Day 2
What fast food restaurants do you typically dine-out? How many times a week?
What Type of Exercise of Sports do you practice? List how often and the length of activity?
DISCLAIMER
(Required)
I agree to the Disclaimer Terms & Conditions
My purpose in seeking Food Beautiful assistance is to establish a healthy lifestyle and nutritional program that supports the body so it may have optimal health and wellness.
I acknowledge that health and wellness is a state of optimal physical, mental, emotional and spiritual wellbeing and not merely the absence of disease or symptoms.
I understand the importance of nutrition and the benefits of dietary supplements to health and disease prevention and that there is scientific documentation on the significant effects on overall health.
I understand that the human body has the innate wisdom to heal, repair and rebalance itself when supported by appropriate lifestyles and nutritional components.
I further understand that sometimes changes in diet and lifestyle are uncomfortable and may have negative results or effects on the body.
With that understanding in mind I seek Food Beautiful assistance for promoting and encouraging overall health and wellbeing. I believe Food Beautiful and Sarah King Feldman have my best interests in mind and are working with me to help me become more aware of my own health and the choices I make.
I understand that Sarah King Feldman is not a licensed medical practitioner, only a Holistic Nutritional Consultant, and that she does not diagnose, treat, cure or make any recommendations concerning the treatment of disease conditions. I recognize she does not make any medical claims and that making lifestyle and nutritional changes are not treatment.
I also understand that any lifestyle and nutritional recommendations Sarah King Feldman makes are not to replace or conflict with the sound advice of my medical physician or health care professional. Any diet or supplement suggestions will be considered as recommendations which I feel are in my best interest. It is my choice to use Food Beautiful services to benefit me. Food Beautiful and Sarah King Feldman are not liable for any damages, rashes or illnesses that may occur during or after services that have been completed.
I understand That Shine Integrative Health and Food Beautiful have a strict 24-hour cancellation policy. Missed appointments without 24 hour notification (by email or phone) are subject to the full price of the session or forfeiting a session if a package was purchased. We have a 72 hour refund policy from time of purchase (on packages) for services not rendered and there is a $75 administration fee. Anytime after 72 hours of package purchased refunds are not issued.
I have carefully read, understand and fully accept the above statements.
Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Signature
(Required)
Comments
This field is for validation purposes and should be left unchanged.
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