Newtritional Solutions - Helping Clients Achieve Their Wellness Lifestyle Goals

Date:
Name:
Street Address:
City/State/Zip Code
Phone:	Home ( ) -
	Cell ( ) -
Best Time To Call:	A.M. P.M.
Email:
	DOB Sex Height Weight
	Married Single Divorced
Occupation:
Children?	If so, what are their ages?
Describe your normal day's eating (in terms of food choices, amounts):
Breakfast

Lunch

Dinner

Snacks

Sugar Substitutes and how often used
How many meals do you eat our weekly?
Describe your normal day's fluid intake:
Water (how many glasses/bottles)?
Coffee/tea (decafe/cafe)?
Alcohol (how many drinks per night/week/month)?
Juice (how many per day, what kind)?
Soda (how much per day, what kind)?
Milk or Soy
Other
How much sleep do you get on an average night?
Is the sleep restful?	Yes No
Do you wake to void?	Yes No
Do you have urinary urgency and/or frequently?	Yes No
Describe your normal bowel routine (diarrhea, constipation, 1,2 or more bowel movements per day)

Describe your energy level

Do you feel stressed?	Yes No
What do you do to relieve your stress?

Do you currently see a medical doctor for any reason?	Yes No
Have you had any surgeries? If so, what were they for and provide dates?

Are you taking any medications? Provide name of meds and what they are taken for.

Please list supplements you are currently taking.

Do you have any food allergies? (list food)

Do you smoke?	Yes No
For how long?
What type(s) of excercise do you, and for how long?

Do you currently have problems with any of the following? Check all that apply:

	Allergies	Headaches
	Joint aches	Leg cramps
	Dizzy spells	Fluid retention
	Constipation	Digestive problems
	Skin problems	High blood pressure
	Nervous tension	Mood swings
	Depression	Kidney problems
	Respiratory problems	PMS/Menopause
	Menstrual cramps	Heart problems
	Weight gain	Weight loss
	Visual problems
Do you have food cravings such as chocolate, peanut butter, breads, alcohol or sweets?

What is your main concern for this consultation?

To the best of my knowledge, I have fully disclosed all medical conditions and medical history as well as any other conditions that may affect my Wellness Consultation and/or Ion Foot Cleanse Detox treatments with Newtritional Solutions. By checking the box below, I agree to this statement. You must click one of the buttons below.
	Medical Statement Yes No

NewtritionalSolutions.com
LIABILITY STATEMENT

•	Newtritional Solutions is a nutritional and wellness consultation service, and is not medical institution nor a medical physician.
•	If you are currently under the care of a licensed physician, any prescribed medication you are taking should not be altered without first consulting and getting the approval from the doctor who prescribed it.
•	If you choose to be a client or Newtritional Solutions, you do so with the understanding that Certified Nutritional and Wellness Professionals are trained specialists that recommend natural vitamins, minerals, herbs and further dietary recommendations to create a balanced environment in the body.
•	If you choose to be a client of Newtritional Solutions, you do so based on the belief that the body has a natural ability to heal itself, if given the appropriate internal and external healing environment.
•	Anything said, done, typed, printed, or reproduced by Newtritional Solutions is NOT intended to diagnose, prescribe, treat or take the place of a licensed physician.
•	Signs of mental stress, supplemental or dietary deficiencies may be identified during a consultation with Newtritional Solutions. Information may be discussed during a consultation about traditional uses of supplementation which may create a healthy balance in the body. This is NOT intended to be interpreted as a substitute for a licensed physician´s treatment.
•	I understand and accept the above statements for my consultations today and in the future with NewtritionalSolutions.
•	I understand that before a wellness and dietary program can succeed, it will take ongoing commitment from me as well as effort and devotion to any lifestyle changes necessary to achieve my wellness goal.

By checking YES in the button below, you have indicated that you have read, understood, and accept the above statements concerning Newtritional Solutions’ services provided to you as a client. You must click one of the buttons below.

Liability Statement Yes No