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Nutrition: Medicine of the future form

Name:
Date of Consultation:
Postal Address:
Sex:
Male Female
Age:
E-mail:
Date of Birth:
Tel No (h):
Blood Type:
Tel No (w):
No of Children:
Tel No (c):
Weight (kg):
Fax No:
Height:
Profession:

Are you taking any Vitamins(Supplements)?
Are you taking any medication?
Hospitalisation. When and what for?
Exercise History:
Times per week:
Do you smoke?
Yes No
Length of session:
Do you use Contraception?
Yes No
Intensity (Hard, Light, Med)
What form?
Do you suffer from Premenstrual tension?
Yes No
Do you suffer from Bloating?
Yes No
Do you suffer from Menopausal problems?
Yes No
Do you suffer from Diarrhoea?
Yes No
Do you suffer from Candida?
Yes No
Do you suffer from Swelling?
Eyelids: Yes No
Fingers: Yes No
Ankles:  Yes No
Do you suffer from Constipation?
Yes No
Do you suffer from Colds?
Yes No
Do you suffer from Sinusitis Problems?
Yes No
If suffer from Colds, how often?
Are you Fatigued?
Yes No
Any headaches?
Do you suffer from Allergies?
Yes No
Joint or muscle cramps?
Do you suffer from Digestive problems?
Yes No
Please describe the allergies and/or digestive problems.

Family History?
High Blood Pressure: Yes No
Liver Disorder: Yes No
Coronary Heart disease:  Yes No
Diabetes: Yes No
Cancer: Yes No
Beverages?
Wine? How much? 
Filtered or tap water? 
Coffee? How often? 
Tea/Herb Tea 
Juices 
Appetite:
Doctors diagnosis:
Have you ever followed a diet programme?
(If so, what types?)

What are your goals?
General daily eating habits and pattern
Breakfast: 
Mid Morning snack: 
Lunch: 
Mid Afternoon snack: 
Dinner: 
After dinner snack: 

Please indicate which programme you would like to follow. Allow 2 to 3 days for response. 
Programme Price Order
Detox Programme (7days) R300.00
Optimum Health Maintenance Programme R300.00
Blood Type Programme (Your blood type is essential) R300.00

After I receive your Form, I will determine the most effective Eating Programme,
which will enable you to achieve your goals.

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