Name Date

TO THE CLIENT: Please list below the five main physical complaints you have in order of their importance:

1.)

2.)

3.)

4.)

5.)

History of illness and treatment:

What was the last medical physician’s diagnosis:

When:

List current medications being taken:

Operations, accidents or injuries:

How many bowel movements per day do you have?

List foods most often craved:

How much red meat do you consume weekly?

What is your weekly carbonated beverage intake?

What is your daily water intake?

What does your exercise routine consist of?

List Current nutrition now being taken: