Shelly Meier C.N.H.P.
Certified Natural Health Professional

Client Health Information Sheet
Name ___________________________________________________ Day Phone _________________________________ Address _________________________________________________ Night Phone _______________________________ City ____________________________________________________ Cell Phone _________________________________ State/Zip ________________________________________________ Email _____________________________________
Relief from what top 3 symptoms (see back page) __________________________________________________________ Life Goals ___________________________________________________________________________________________ How much sweaty activity weekly? ___________________________ What type of activity? ________________________ How many ounces of water do you drink daily? _________________ What type?     RO        Tap       Spring       Distilled    Which meals daily eaten?       Breakfast       Lunch        Supper How many eliminations per day? _______________ How many digestive enzymes daily? __________________________ How many breathing exercises daily? ___________
How much of the following do you consume? (example, 1D = once daily, 3M = 3 times monthly)  Soda pop _________ Coffee  ________ Smoking ___________ Alcoholic Bev __________ Fast food _________ Milk ___________ White Flour _________ Sugar usage ___________ Raw fruit __________ Meat __________ Raw Veggies ________ Whole Grains __________
What types of food do you crave?     Salty        Chocolate       Sweets       Breads        Other ____________________________ What are your favorite foods? __________________________________________________________________________ How much daily energy (1 = lowest energy level; 10 = highest energy level) do you have? __________________________ What surgeries have you had and when? Circle NONE if applicable.  ____________________________________________ ___________________________________________________________________________________________________ How many hours of TV do you watch?    Daily ___________________ Weekly ____________________________________ How many hours of spiritual enrichment each week? (Bible, prayer, church, etc.) __________________________________ How many hours a week do you spend with family/friends? __________________________________________________ How many hours of sleep do you get each night? _______________ How many hours do you need? ________________ What kind of prescription medication do you take?  Circle NONE if applicable. ___________________________________ ___________________________________________________________________________________________________
Would you like to receive our natural health newsletter?        YES            NO Who referred you for your appointment today? ____________________________________________________________
I understand that I am here to learn about nutrition and better health practices and that I will be offered information about food supplements and herbs as a guide to general good health and this is a personal ministry and spiritual counseling. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purposes or treatment procedures.  I am not on this visit or any subsequent visit an agent for federal, state, or local agencies or on a mission of entrapment or investigation.   The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health and do not involve the diagnosing, treatment, or prescribing of remedies for disease. 

 


Signature ________________________________________________ Date ______________________________________
















 



Rate the following categories  (1 = needs considerable improvement; 10 = excellent).
Deep breathing 1 2 3 4 5 6 7 8 9 10
Water intake and type 1 2 3 4 5 6 7 8 9 10
Good food intake 1 2 3 4 5 6 7 8 9 10
Junk food intake 1 2 3 4 5 6 7 8 9 10
Bowel movements 1 2 3 4 5 6 7 8 9 10
Exercise 1 2 3 4 5 6 7 8 9 10
Stress or emotional levels 1 2 3 4 5 6 7 8 9 10
Spiritual balance 1 2 3 4 5 6 7 8 9 10
What they do for fun (emotional release) 1 2 3 4 5 6 7 8 9 10
Chiropractor or massage visits 1 2 3 4 5 6 7 8 9 10
pH of urine and saliva 1 2 3 4 5 6 7 8 9 10
Current nutritional supplements & why 1 2 3 4 5 6 7 8 9 10
Amount of rest needed vs. received 1 2 3 4 5 6 7 8 9 10Rate the following categories  (1 = needs considerable improvement; 10 = excellent).
Deep breathing 1 2 3 4 5 6 7 8 9 10
Water intake and type 1 2 3 4 5 6 7 8 9 10
Good food intake 1 2 3 4 5 6 7 8 9 10
Junk food intake 1 2 3 4 5 6 7 8 9 10
Bowel movements 1 2 3 4 5 6 7 8 9 10
Exercise 1 2 3 4 5 6 7 8 9 10
Stress or emotional levels 1 2 3 4 5 6 7 8 9 10
Spiritual balance 1 2 3 4 5 6 7 8 9 10
What they do for fun (emotional release) 1 2 3 4 5 6 7 8 9 10
Chiropractor or massage visits 1 2 3 4 5 6 7 8 9 10
pH of urine and saliva 1 2 3 4 5 6 7 8 9 10
Current nutritional supplements & why 1 2 3 4 5 6 7 8 9 10
Amount of rest needed vs. received 1 2 3 4 5 6 7 8 9 10

 


 


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