Please complete ALL FOUR sections of the Application.

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Nutritional Therapy Application Step 1/4

Name

Check any known health conditions or diseases here:

Diabetes‎ Cancer‎ Heart Disease‎ Obesity‎ Liver Disease‎ Kidney Disease‎ Autoimmune Disorder‎ Eating Disorder‎ None of the Above‎

Mark Any/All medications you have taken in the past month:

Blood Pressure Medication‎ Cholesterol-Lowering Drugs (Statins)‎ Birth Control Pills/ Hormone Replacement‎ Painkillers‎ Synthetic Thyroid‎ Acid Blockers/ Antacids‎ Antidepressants‎ NSAIDS (Aspirin, Ibuprofen, Etc.)‎ Antibiotics‎ None of the Above‎

Please mark any symptoms you experience regularly:

General

Insomnia‎ Frequent Colds‎ Stomach Pain‎ Headaches‎ Muscle Cramps‎ Muscle Weakness‎ Excessive Thirst‎ Excessive Sweating‎ Low Blood Pressure‎ Joint Pain‎ Back Pain‎ None of the Above‎

Energy, Brain Function and Mood

Low Energy‎ Daytime Drowsiness‎ Hyperactivity‎ Poor Memory‎ Poor Concentration‎ Brain Fog/Confusion‎ Depression‎ Anxiety/Tension‎ None of the Above‎

Skin, Hair, Nails, Eyes, Mouth and Appetite

Acne/Oily Skin‎ Poor Skin Elasticity‎ Dry, Flaky Skin‎ Easy Bruising‎ Hair Loss‎ Dry Scalp‎ Oily Hair/Scalp‎ Brittle Nails‎ Bright Light Sensitivity‎ Burning/Bloodshot Eyes‎ Reduced Night Vision‎ Cold Sores‎ Bleeding Gums‎ Tooth Decay‎ Frequent Hunger‎ Poor Appetite‎ Nausea When Eating‎ Weak Sense of Smell‎ Intense Food Cravings‎ None of the Above‎

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