For the Love Of Mangoes
About
SobrieTea
Services
Recipes
Blog
Web Site
First Name
*
Last Name
*
Street
*
Province
*
- Select Province/State -
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
====================
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Date of Birth:
*
Phone Number
*
City
*
Postal Code
*
Email Address
*
Occupation
*
Hours Per Week
Family Health History
*
Do you have pets?
*
What cardio do you do? How often/duration?
*
What weight training do you do? How often/duration?
*
What relaxation exercise do you do? How often/duration?
*
Do you experience digestive difficulties? Ex: bloating, indigestion, gas, constipation. Describe.
*
Do you have a bowel movement every day? If so, how many per day?
*
List any known food or environmental allergies and intolerances.
ie: hay fever, grass, lactose intolerance, etc
Provide complete details on your entire health history and be as specific as possible
*
Try to remember antibiotic courses, recurring infections, surgeries, oral health, diagnoses, history of medications, etc
List all supplementation you are taking:
This can be herbs, teas, tinctures, vitamins, minerals, protein powders, greens powders, etc.
Describe any health issues or problems you are currently experiencing. Specify your main concern:
Is there anything in your life that will get in the way of following a treatment plan?
Coffee?
*
Yes
No
Black Tea?
*
Yes
No
Carbonated Beverages?
*
Yes
No
Alcohol?
*
Yes
No
List 3 foods you cannot live without
*
Provide any other information you think may be relevant to your diet.
How much water do you drink per day?
*
Water Source?
*
Tap Water
Filtered Water
Purified Water
Reverse Osmosis
Bottled Water
Other
How many fruit per day?
*
How many vegetables do you eat per day?
*
Do you buy organic?
*
Yes
No
When possible
What do you wash non-organic produce in?
*
Vegetable rinse
Peroxide
Water
None
Other
Is your occupation stressful? Describe.
*
Are there any stressful relationships with colleagues or management?
*
Are there stressful relationships with family members?
*
Provide any further information that is relevant to emotional life.
*
Which of the following do you use?
*
Microwave
Electric Blanket
Water Bed
Smart Watch
None of the above
How often do you travel by plane?
*
Are you exposed to fluorescent lighting at home or at work?
*
Yes
No
Do you use a computer at home or at work?
*
Yes
No
Do you use a cell phone?
*
Yes
No
List 3 health goals you wish to attain for yourself:
*
By submitting this form, I hereby attest the following: That I am here, on this and any subsequent visit, solely on my own behalf and not as an agent for any government agency on a mission of entrapment. I fully understand that Kayla Roy is not a medical doctor and I am not here for medical diagnostic or treatment procedures. The services performed by Kayla Roy are at all times restricted to the consultation on the subject of nutrition intended for building wellness and do not involve the diagnosing, prognosticating, treating or prescribing remedies for the treatment of disease, or any act which a medical license or medical authorization is required. This agreement is being signed voluntarily and not under duress of any kind.
*
I have read and agree to the terms stated above.
Date
*