New Client Questionnaire

Please provide the following information before your session.

First Name (required)

Last Name (required)

Email (required)

Phone (required)

Birthdate

What are your goals and/or health concerns?
 Enhanced Energy Levels Skin Complexion & Care Weight Loss Healthy Family & Kids Recipes & Cooking Other

Current Weight (lbs)

Current Height (ft' in")

Occupation

What medical conditions are known in your family?

Do you currently take any pharmaceutical drugs or hormones?
 Yes No

If yes, please list each one (name, dosage, frequency):

Do you drink coffee?
 Yes No

If yes, how much per week?

Do you drink soda?
 Yes No

If yes, how much per week?

Have you ever smoked tobacco?
 Yes No

If you currently smoke, how much per week?

If you stopped smoking, when did you quit?

Do you use recreational drugs?
 Yes No

If yes, how much per week?

Do you drink alcoholic beverages?
 Yes No

If yes, how much per week?

--Please describe your daily meals--

Breakfast

Lunch

Dinner

Snacks

Cravings

Please tell us other important health considerations you may have. The more specific and descriptive your information is, the more we will be able to help you.

Agreement & Understanding Prior to Consultation with Lauren Talbot
I do hereby acknowledge that Lauren Talbot states to me that she is an educator and a holistic health counselor and that she is not a licensed (allopathic) medical doctor or licensed primary health care provider. I state that I come to Lauren Talbot with the purity of purpose of seeking more information. I state that I do not come with any forethought or desire for entrapping Ms. Talbot into an illegal statement. If I am a member of the A.M.A., the F.D.A., or any law endorsement agency, or any city, county, state or federal regulatory agency, then I will identify myself as such before the appointment begins. I understand that Ms. Talbot’s sole intention is offering to me general education information I request. If I choose to use this information to work on myself then I affirm that the responsibility is mine. I understand Ms. Talbot to feel one should never use her information in any way that contradicts, conflicts, or opposes a course of treatment recommended by a primary health care provider such as a licensed medical doctor. If I ever perceive or feel that information given by Ms. Talbot opposes a licensed doctor’s treatment or recommendations, Ms. Talbot strongly advises me to follow the advice and instruction of my licensed primary health care provider. I understand that Lauren Talbot is not providing medical services. I will not consider anything she says to substitute in any way for consultation, diagnosis and treatment by a licensed primary health care provider, such as an M.D. Lauren Talbot is not a licensed medical doctor (M.D.) or licensed primary health care provider. She does not diagnose, prescribe, or treat symptoms, defects, injury or disease. This appointment is for educational purposes only. If I want medical advice or treatment, Lauren Talbot encourages me to consult with a licensed primary health care provider. I consult with Lauren Talbot in her capacity as a Naturopathic Educator and Holistic Health Counselor who conveys self-help information that people can use to increase their own health and well being. I affirm my right to self-health and I take full responsibility for my healing process.

By checking this box, I do hereby voluntarily state to understand and acknowledge as accurate all the above comments.

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