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Name

Name


What is your email Address?

What is your email Address?


Please describe your condition:

Please describe your condition:

ex: I experience pain in my joints, I am fatigued during the day

How long you've had your condition for

How long you've had your condition for


  Eating Habits:

Eating Habits:

Which best describes your eating habits

Which best describes your eating habits

What time do you usually eat dinner?

What time do you usually eat dinner?


How big are your portion sizes for dinner?

How big are your portion sizes for dinner?


Does your dinner make up 30% or 50% of your food intake for the day?

Does your dinner make up 30% or 50% of your food intake for the day?


After you eat, do you feel bloated?

After you eat, do you feel bloated?


  Drinking Habits:

Drinking Habits:

How do you drink your water?

How do you drink your water?

  Heart Rate:

Heart Rate:

What is your heart ratio in one minute on your wrist?

What is your heart ratio in one minute on your wrist?


Is your Heart Rate:

Is your Heart Rate:

  Tongue:

Tongue:

Please take a mirror, look at your tongue

Please take a mirror, look at your tongue

Colour of tongue:

Coating:

Coating:

Colour of coating:

Colour of coating:


  Sleeping Quality:

Sleeping Quality:

Do you sweat overnight?

Do you sweat overnight?


When you go to bed, do you feel your extremities are cold?

When you go to bed, do you feel your extremities are cold?


How many times do you wake up durng the night?

How many times do you wake up durng the night?


Do you need to pee everytime you wake up during the night?

Do you need to pee everytime you wake up during the night?


When you wake up, do you feel refreshed?

When you wake up, do you feel refreshed?


  Urine Profile:

Urine Profile:

How do you pee during the day

How do you pee during the day


When you pee during the day, is the pee strong or weak?

When you pee during the day, is the pee strong or weak?

Do you sweat easily during the daytime?

Do you sweat easily during the daytime?


During the day, do you feel cold and hot spells that come and go?

During the day, do you feel cold and hot spells that come and go?


  Bowel Movements:

Bowel Movements:

How often do you have bowel movements?

How often do you have bowel movements?


Is the stool:

Is the stool:


  Medications & Supplements:

Medications & Supplements:

Please list all medications/supplements and why you are taking it:

Please list all medications/supplements and why you are taking it:


Please describe how you take your medication/supplement:

Please describe how you take your medication/supplement:


Calendar

Calendar

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Hamilton, Ontario, Canada
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