Path To Perfect Health - essential oils, holistic health, natural foods, nutrition, food charts, raw food recipes, go green

Phone: (626) 497-8627 or (928) 753-9220

pre-consultation health survey

First name:

Last name:

Email:

Confirm email:

Phone:

Birth Date:

mm/dd/yyyy

Place of Birth

Birth Address:

max 40 characters

Birth City:

max 40 characters

Birth State:

Please answer as many of the following questions as you can.

Have you used over the counter drugs during the past year?

Are you currently using a synthetically produced drug?

Are you currently using any type of steroid drugs?

Do you smoke tobacco products?

Do you currently have amalgm dental fillings?

Do you have unresolved mental issues?

Do you feel responsible for your own health?

What is your level of stress?

How often do you exercise?
(for a minimum of 20 minutes)

How many of the following do you consume each day on the average?

Food and drinks containing processed sugars:
Alcoholic beverages:
Caffiene drinks:
Glasses of water:

Have you had past major physical injuries?

Have you had past major infections?

How is your weight for your body type?

Estimate the percent fat in your diet:

Have you ever been diagnosed with and of the following?
Check all that apply.

Do you currently suffer from any of the following:
Check all that apply.

Additional Comments: