Take the Health Questionnaire

Written by Administrator

Tuesday, 12 August 2008 00:17

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(Please feel free to print this out and FAX it back to us!)

Health Questionnaire

Name: _____________________________________________________________

Address: __________________________________________________

Phone: ________________ Email:____________________________

Date of Birth: _______________ Height ____________Weight _____________






Medical History:




Names and dates of past ailments, prior surgeries, any current illness being treated for? Any health complaints/symptoms? On any medication? ______________________________________________________________________________________________________________________________________________________ Do you use any supplements?? _________________________________________________

Eating Habits

Do you eat breakfast? Do you snack between meals?
Do you wake up during the night to eat?

Do you overeat at mealtime?



Do you snack between your meals?

Do you crave sugar, starches, carbs, sweets?

Are you following any special diet now?



What time do you get to bed?
What time do you wake up?
Do you feel rested after a good night's sleep?
How often do you exercise?


How do you feel after you exercise, energized, exhausted or winded?

Tobacco Use

Do you smoke or chew tobacco?
If so for how many years?

Alcohol Consumption

Do you drink alcohol?

How often?

Beverages:

How much water do you drink daily?

What other beverages do you drink daily?

Soda	How many bottles much per day?
Coffee	Number of cups per day?
Tea	Number of cups per day?
Fruit juice	Type and amount each day?

Milk	Amount per day?
Other	Type and amount?

Do you eat desserts, candy or other sweets regularly?

Do you have any food allergies…wheat, gluten, soy, eggs, lactose???

Disclaimer:

I agree to allow Connie Pridgen, CNC, who is Certified in the field of Nutrition and Wellness, aka Messenger of Health, to design a weight control and/or supplementation program for myself in the quest to enhance my personal health and well-being. I will follow the program to the best of my ability and will not hold Connie Pridgen, CNC, liable for any problems, illnesses, injuries that may occur due to a sudden change in my eating, or addition of supplementation or exercising habits. I understand that Connie Pridgen, CNC, is not a doctor or registered nurse but Certified in the field of Nutrition and Wellness and Clinician with Sabre Sciences. The weight control program does not replace the expert advice or medical treatment of my own physician. I have answered all the questions regarding my personal health, including any medications and supplements that I either currently am taking or have taken in the past in the above Health and Wellness Questionnaire.

Please indicate that you understand that this questionnaire and the educational information given in this consultation is not intended to diagnose or to treat any disease, ailments or abnormality, and that it serves as background information in order to ADVISE you on a healthier lifestyle according to your condition.

I understand and have read the disclaimer:

YES

Your Order is
Item	Unit Price	Qty	Total
Initial in-person or 25 minute telephone nutrition consult.	$45.00	1	$45.00

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Disclosure statement:

These statements have not been evaluated by the FDA. These products are not intended to diagnose, treat, cure or prevent any disease. All products and prices may not be available for shipping to all locations.

Sabre Saliva and/or Urine Test kits can be ordered and added to your protocol at any time and are not part of your initial consult fee.

Please keep in mind: Sabre Saliva and/or Urine test kits cannot be sold or shipped to NY residents.

Last Updated on Thursday, 26 May 2011 04:14