The Health Nerd. Let your food be your medicine

Consultation Questionnaire

First Name
Email address you would like protocol sent to:
Gender: Male Female
Age:
Height: feet/in meters/cm
Weight: Pounds Kilos
Are you currently dealing with any medically diagnosed condition?:
If yes please state:
Yes No
How would you rate your stress level in the last 6 months?:
Minimal Average Extreme
What are the sources of your stress? Click on all that apply:
Mental Emotional Career/Job Health Family Financial
Do you smoke?
No Occasionally Daily
Do you drink alcohol?
No 1-2 drinks/week 3-5 drinks/week 7+ drinks/week
Do you regularly use recreational drugs?
If yes, please state type:
No Yes
How many hours of sleep/night do you have on average:
How many hours do you sleep between 11pm and 8am:
How would you rate your level of physical activity?
Minimal (exercise 1hr./wk or less)
Medium (exercise 3hr/wk average)
High (exercise 5hr/wk or more)
How would you rate your diet?
Poor (junk food/sugar/caffeine)
Average (non-organic/mostly healthy/junk,sugar,caffeine in moderation)
Excellent (organic/fruit,veg,grains high/meat low/junk,sugar,caffeine low)
Have you ever been diagnosed with a food allergy?
If yes, please state what food(s)
No Yes

Do you regularly experience any of the following digestive issues? :
Heartburn/Acid reflux
Severe gas or bloating after meals
Diarrhea or intestinal pain after meals.
Do you have regular bowel movements?
How often?
Yes - 1/day or more No
Do you currently have any rashes, eczema, or psoriasis?
If yes, please state where
Yes No
Do you regularly experience any of the following fungal issues?
Athlete's foot
Nail fungus
Jock itch
Vaginal yeast infection
Do you have ongoing problems with any of the following:
Cavities
weak/brittle nails
weak/brittle hair
muscle cramps
Have you been on antibiotics in the last 2 years?
Yes No
Are you currently taking any prescription (pharmaceutical) medication?
Yes No
Do you have mercury amalgam (silver) fillings in your teeth?
Yes No
Does your occupation involve exposure to chemicals, heavy metals or known toxins?
Yes No
Do you live near power lines or an industrial factory?
Yes No
Do you use a cell phone?
If yes, how often?
Yes No
Minimal Daily Frequent
Please describe the health concern you would like to consult The Health Nerd.com about. (Only 1 health concern per consultation will be addressed.)