Consultation Information Form

Name:                                                                                                           

Date:

Birth Date

Referred By:

Occupation:

Blood Type:

What improvements would you like to make in your health?

What surgeries or medical problems have you had?

What medications are you presently using? 

Parents Names:

Siblings Names, in order of birth (including self):

Miscarriages Mom had or loss of a child

Significant Others Name/Names

Names of deceased relatives, friends, pets

Thank you for requesting a consultation.  It is my goal to teach you about the deepest parts of yourself and to encourage you in making the best, appropriate choices in the care of your whole being. 

We encourage eating according to your blood type. 

Please fill out questionnaire the best that you can with as little stress as possible!  Include dates when ever possible.

Whenever taking a new supplement, please begin with one the first day and increase by each day until you reach the full amount suggested.  Always make sure you keep your bowels moving daily.

  Many Blessings, Love and Light,           

 Joyce