First Visit Forms


First Visit Forms

Please fill out this form to the best of your knowledge 

For example: managing weight, improving energy levels, addressing chronic illness, better meal planning, etc

For example: lowering blood sugar, reducing stress, achieving a healthy weight, or improving digestion.

1 means "I don't feel ready to make changes" and 10 means "I am fully ready to take the necessary steps toward my health goal" 

For each item, include the following details:

  1. Meal Time (e.g., Morning, Mid A.M., Mid Day, Mid, Night)
  2. Food/Drink Name
  3. Amount Eaten (e.g., 1 slice, 2 cups, 200g)
  4. Cooking Method (e.g., boiled, fried, raw)
  5. Additives (e.g., salt, sugar, sauces)
  6. Remarks (e.g., homemade, low-sodium, organic)

If less than five hours of sleep fill out
If less than five hours of sleep fill out
If less than five hours of sleep fill out
If less than five hours of sleep fill out
If less than five hours of sleep fill out
If less than five hours of sleep fill out
If less than five hours of sleep fill out
If less than five hours of sleep fill out
If less than five hours of sleep fill out
If less than five hours of sleep fill out
If less than five hours of sleep fill out
If less than five hours of sleep fill out
If less than five hours of sleep fill out
Indicate if the location has Excess Dust /Fumes, Hot & Humid, Molds, Peeling Paints, Clutter, Noise, Lack Of Greenery, and/or Walking/Riding Path
Indicate if the location has Excess Dust /Fumes, Hot & Humid, Molds, Peeling Paints, Clutter, Noise, Lack Of Greenery, and/or Walking/Riding Path
Indicate if the location has Excess Dust /Fumes, Hot & Humid, Molds, Peeling Paints, Clutter, Noise, Lack Of Greenery, and/or Walking/Riding Path
Indicate if the location has Excess Dust /Fumes, Hot & Humid, Molds, Peeling Paints, Clutter, Noise, Lack Of Greenery, and/or Walking/Riding Path
Indicate if the location has Excess Dust /Fumes, Hot & Humid, Molds, Peeling Paints, Clutter, Noise, Lack Of Greenery, and/or Walking/Riding Path
Submit

 Thank You for Your Submission 

Please take a moment to review our cancellation policy to ensure a smooth experience. 

If you have any questions, feel free to reach out. 

See you soon!