Health Assessment Form

Curious about your health and how it may relate to your diet, lifestyle, stress levels, etc.? Look no further. Fill out our form and a nutritional specialist will assess and provide you with great, free feedback and suggestions!

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What does your daily diet consist of? Please be as detailed as possible including all meals, snacks, and beverages.

How many ounces of water do you consume each day?

Do you consume alcohol? If so what kind and how often:

What is the source of your water?   Tap Filtered Distilld Bottled

List any vitamins and/or supplements you take daily:

Please list any medications you take each day:

Are you overweight?   Yes No

Do you often deal with a lot of stress?

Have you been prescribed any antibiotics within the last 6-8 months?

Do you have any problems with urination or bowel movement frequency?

Gout/Arthritis/Joint Pain/Inflammation History: List how many years you have suffered, the severity of your attacks, and the frequency:

What is your current pain status and attack location?

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