CLIENT QUESTIONNAIRE & DISCLAIMER

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Headaches
Migraines

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Digestive Problems
Diarrhea
Constipation
Gas after eating

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Acid reflux
Insomnia
Urination at night

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Adult acne
Eczema
Dandruff /Flaky Scalp

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Arthritis
Joint Pain

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Poor Concentration
Ringing in ears

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Low Back pain
Upper Back Pain
Hormone Imbalance
Painful Menstruation

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Hypothyroidism
Low Sexual Drive
Eat sweets daily

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Drink Soda

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Drink Alcohol

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Drink Tea
Drink Coffee

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Drink Juice
Chew Gum
Smoke
Use Marijuana

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Take Recreational Drugs
History of Cancer
History of Heart Disease

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
What do you eat for Lunch? (please provide serving size) and time.
What do you eat for Snacks? (please provide serving size) and time.
What do you eat for Dinner? (please provide serving size) and time.
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This field is for validation purposes and should be left unchanged.

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