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Global Nutrition New Client Intake Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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###

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Phone

(###)

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What is your date of Birth?

Who is your employer and what do you do there?

How did you hear about us?

Health Goals

What are your main health concerns or goals?

Please rate your energy level on a scale of 1-10. with 10 being the best during the day?

Medical & Health History

Primary Care Provider or Specialist

What are your surgeries and major illnesses?

Have you had Genetic testing or any recent blood work?

Current Supplements and Herbs and manufacturers

Current Medication and Dosage (including over the counter-advil, tylonal allergy meds and more)

Please list all vaccinations?

What is your height and weight?

Allergies and Sensitivities

Current Diagnoses

Lifestyle and Nutrition

Describe daily meals and snacks

Have you been Pregnant, Miscarried, C-Section or had any abortions?

How many children do you have?

How much alcohol a week? how much tobacco? how much recreational drugs a week?

How much do you exercise?

what is your current stress level 1-10?

What are your main sources of stress?

What makes you feel relaxed and grounded?

Consent and Acknowledgment

I understand that my nutritional assessment is educational and supportive, not a medical diagnosis or treatment. I acknowledge that i am responsible for my own health.

Cancellation and Return Policy

Global Nutrition requires 48 hr notice for cancellation or you will be charged full service. Global Nutrition does not accept any returns for service/supplements

Wellness Programs and Pricing

If your appointment is virtual, please click link below to get directions

Virtual iridology Instructions