directconnectionwellness@gmail.com
Name:
Date:
Birthdate:
Age:
Sex: MaleFemale
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Occupation:
Do you primarily: SitStandPerform repetitive tasks
Are you: SinglePartneredMarriedDivorcedWidowed
How did you hear about the SHAPE Program?
What health benefits do you want to achieve with the SHAPE Program? Improved eating habitsImproved well-beingDecreased inflammationWeight lossIncreased energyImproved sleepIncreased staminaOther
If other, Explain?
Height:
Weight:
Are there any areas of your body that are not functioning optimally? YesNo
If yes, explain:
On average, how many hours do you sleep per night? <5678910
Do you wake up feeling refreshed? AlwaysSometimesRarelyNever
Have you ever been hospitalized or had surgery? YesNo
If yes, why and when?
Have you been diagnosed with any clinical condition or disease? YesNo
If yes, what?
Have you ever been in a motor vehicle accident? YesNo
If yes, what kind and when?
Were you evaluated and treated after the accident? YesNo
Have you had any non-vehicle accidents or falls? YesNo
Have you had any imaging performed in the last year? X-rayMRIUSPETNO
Have you had blood work performed in the last year? YesNo
Were your test results in medically normal ranges? YesNo
If no, which results were abnormal?
Please list the foods you commonly eat for:
Breakfast:
Lunch:
Dinner:
Snacks:
How many cups of vegetables do you eat per day? 01234567+
What foods do you crave?
What are some specific goals you have regarding the SHAPE Program?
Do you choose to get annual flu shots? YesNo
Have you used antibiotics in the last year? YesNo
How many cups of water do you drink per day? 01-34-67-910+
How many glasses of juice/soda/soft drinks do you drink per day? 01-34-67-910+
How many cups of coffee/energy drinks do you drink per day? 01-34-67-910+
Do you eat wheat products (bread/pasta/crackers/baked goods)? YesNo
If yes, how many servings per day?
Do you eat refined sugar? YesNo
Do you ingest artificial sweeteners (Splenda, Aspartame, Equal, diet drinks, gum) ? YesNo
Do you have any food/drink allergies, sensitivities or intolerances? YesNo
If yes, Explain?
Do you smoke? YesNo
I used it for:
Are you/have you been exposed to second-hand smoke? YesNo
Do you take probiotics? YesNo
Do you take Vitamin D? YesNo
Do you take Omega-3? YesNo
Other supplements:
Please list any medications that you take regularly and why:
Rate the current level of personal stress in your life: NoneLowModerateHigh
Rate the current level of relationship stress in your life: NoneLowModerateHigh
Rate the current level of health stress in your life: NoneLowModerateHigh
Rate the current level of family stress in your life: NoneLowModerateHigh
Rate the current level of occupational stress in your life: NoneLowModerateHigh
How do you manage the stress in your life?
I , hereby grant permission to receive a professional and complete physical examination and consultation, including urinalysis and evaluation.
Signature:
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