Personal Health History

Women Only (Please skip if you are Male):

CLIENT INTENTIONS:

I, hereby swear that the above information is correct to the best of my knowledge. I acknowledge that it is my responsibility to divulge all personal information for the purpose of informing my Nutrition Therapist that she/he may apply the necessary protocol to achieve my health and nutrition goals. I also understand that it is my responsibility to actively engage in this process that I might achieve the desired results.

Thank you for taking the first step in reaching your goals!