Please fill out the below form and then click on submit. We will be in touch with you after reviewing your form. Thank you. CommentsThis field is for validation purposes and should be left unchanged.1) Do you consider yourself in good physical health? Yes No 2) Are you currently taking any medications? Yes No If yes, what and for how long?3) Do you take vitamin supplements? Yes No If yes, what and for how long?4) Do you have a history at any time in your life or do you currently have any of the following symptoms or body signs?Headaches - How often?Does not eating make them worse? Yes No What makes them better?Dizziness - How often?Does it occur when you bend down to pick something up or get out of a bath quickly? Yes No From missing a meal? Yes No Heart palpitations - how often?Check applicable symptomsKidney or bladder infections Painful urination Frequent urination Burning urination None of the above Lung or respiratory conditions Painful inhalation or exhalation Frequent colds Sinusitis Wheezing Shortness of breath Allergies Asthma None of these Skin Dry Oily Rashes Acne Hives Boils Eczema Psoriasis Allergic dermatitis None of the above How often do you have a bowel movement?Do you ever have blood with your stools? Yes No Check applicable symptoms Heartburn Burping Bloating Nausea Vomiting Gas or flatulence Diarrhea Constipation None of the above 5) Do you crave any specific foods? Yes No If yes, which foods?6) At any time in the past, or recently, have you consumed a lot of sugar, salt, meat, coffee, or any other food? Yes No If yes, which foods?Are you allergic to any foods? Are there any foods your body doesn't like, i.e. coffee -hyper, dairy -mucous, sugar -pre-menstrual symptoms or general fatigue, fatty, rich foods -indigestion, etc.?7) Do you exercise regularly? Yes No If yes, what do you do, for·how long, how many times per week and how long have you been doing this?8) Have you ever or do you now drink alcohol more than 1 time per month? Yes No If yes, how often and what?9) Have you ever or do you now smoke tobacco or cigarettes? Yes No If yes, what, how often, how long?10) What other physical conditions or symptoms have you had recurring or do you have now? ie- headaches, nausea, low energy, etc.11) What surgeries have you had?12) What diet programs have you done in the past and when?What were the results and did you have any symptoms?13) Have you ever been hospitalized for psychiatric care? Yes No 14) Are you currently in therapy? If yes, please inform your therapist you are doing this program and your therapist must verbally O.K. your participation in this program? Yes No 15) Have you ever had an incomplete course in therapy? Yes No Is there anything else we need to know about your physical or emotional health?Please list at least 3 goals you are committed to accomplishing participating the the LOVE YOUR BODY workshop.Name* First Last Age*Email* Home PhoneWork PhoneDate* MM slash DD slash YYYY Δ
