Client information Name * First Name Last Name Email * Date * MM DD YYYY Street Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone or Cell * (###) ### #### Digestive Please check all that apply - Over acid Under acid Stomach problems Hiatal hernia Other Other # of meals per day Emotional/Nerves Please check all that apply - Mood Swings Depression Anxiety, Fear, or Nervousness Anger, Irritability Other Other Lymph, Skin Please check all that apply - Do you sweat often? Do you use an antiperspirant? Hives, Rashes, Dry Skin, Acne Other Other How many times per week do you exercise? How often do you have headaches? Hair/Nails Please check all that apply - Hair Loss Poor Nails Other Other Mind Stress, Poor Memory/Concentration Other Other Elimination/Colon Diarrhea Constipation Other # of bowel movement(s) per day/week Other Glands Irregular Periods PMS/Menopause Symptoms Other Other Urinary Water Retention Kidney/Back Pain Other Other Energy/Activity Fatigue/Sluggishness Hyperactivity/Insomnia Other Other Respiratory Chest Congestion/Coughing/Pain Asthma/Bronchitis/Allergies Stuffy Nose/Sinus Problems Other Other Head/Ears/Eyes/Mouth/Throat Earaches/Ear Infection Ringing in Ears/Hearing Loss Blurred/Poor Vision Sore Throat/Hoarse Other Other Circulation/Heart/Joints Irregular/Rapid Heartbeats Chest Pain Poor Circulation Arthritis Pain or Aches in Joints Other Other Weight Under/Over Weight Binge Eating/Drinking Craving Certain Foods Other Other Current medication(s) Are you allergic to anything? Other Read This: Information provided by TruHealth is not meant to diagnose or prescribe. It is meant for educational purposes, to share research and anecdotes only. Use the information at your own risk. Kasara D’Elene accepts no responsibility from the results you get, whether good or bad, from using information provided. Always seek guidance of a qualified health professional. I have chosen this service as an alternative and have read and understood the above. By typing your name and the date below you are agreeing to the above statement. * Date MM DD YYYY Thank you! I will contact you within 24-48 hours.
