Initial Questionnaire
Name .
Age
Date
City
Address
What are your main concerns or health concerns?
Please list any  medications or food supplements you are currently taking.
Please list any recent medical tests you have had, such as blood work.
Please list any medical conditions in your family history, such as heart disease, diabetes, arthritis or cancer. 
What is an example of a typical breakfast for you, include beverages? 
What is a typical mid morning snack?
Sex
Postal/Zip Code
Province/State
Country
What is a typical afternoon snack?
What is a typical supper for you, including beverages?
What is a typical evening snack?
What is an example of a typical lunch for you, include beverages?
How many hours of sleep do you get per night?
What type of exercise do you do and how often per week?
Name:
Date: 
Signature: 
I understand that nutritional balancing is a means to reduce stress and balance body chemistry. It is not intended as diagnosis, treatment or prescription for any condition or disease. I acknowledge and understand that Marian Verhesen works as an unlicensed nutritional consultant. 

This questionnaire is for informational purposes only and not intended to treat individuals. If clients have a medical diagnosis, they are encouraged to seek out treatment from a qualified medical doctor. Fill in the following form and answer all that you can. 
E-mail Address
Height
Weight
Phone number.
Alcohol use:
Tobacco use:
Recreational Drug use:
Type
​Ounces
How often
Type
How often
Type
How often
Check this box to acknowledge you have read the above disclosure statement