Date Of Appointment (Month/Date/Year) Full Name Date of Birth (Month/Date/Year) Address City State Zip Email Cell Phone Home Phone Pls select your preferred method of communication for future appointment confirmation: - Select - Phone Call Email Text How did you hear about us? (If referred by someone, please list name) Pregnant? - Select - Yes No Breast Feeding? - Select - Yes No Varicose Veins? - Select - Yes No Poor Circulation? - Select - Yes No High Blood Pressure? - Select - Yes No Diabetes? - Select - Yes No In order to determine the condition of your colon, how many bowel movements do you have per day? - Select - 1-2 Per week 2-3 Per week 1-3 Per week Others Are you currently under a physician’s care for any reason? - Select - Yes No If yes, please list reason Are you currently taking any medications? - Select - Yes No Please list Do you have any known allergies to things taken internally or topically? - Select - Yes No What? Height Weight Goal Weight Pants Size Goal Size List areas you would like to trim down What is your greatest lifestyle weakness? Do you crave sweets? - Select - Yes No How much water do you drink daily? How many cups of coffee do you drink daily? How much soda do you drink daily? How often do you consume red meat? (Beef, pork) Chicken, fish seafood? How many servings of fruits daily? Vegetables? Do you smoke? - Select - Yes No Frequently? - Select - Yes No Do you want to quit? - Select - Yes No What herbs/vitamins do you take? What kind of exercise do you do? How often? What are you hoping accomplish by receiving this service or consult today? If you are receiving a contour today, please acknowledge that you understand that you may be allergic to one or more of the ingredients in the cream that is used, which may result in a hive like reaction. Please let us know if this happens and we will use different cream next time. A baking soda bath, calamine lotion and anti-itch products will lessen itching. You must agree before submitting. Electronic Aknowledgement Date Today (Month/Date/Year)
