Holistic Nutritionist, on-line consultation, Cancer Coach, Vancouver, BC

Nutritional evaluation

NUTRITIONAL EVALUATION

Welcome to your Nutritional Evaluation !!!

You can choose to have a partial evaluation or a complete and comprehensive one.

For the partial evaluation all you need to do is to fill-up the questionnaire below and submit it to me. I will send you by e-mail or regular mail (according to your preferences) my evaluation and recommendations.

For the complete evaluation, you have to fill-up the questionnaire below and submit it to me, and you will receive by e-mail “Advanced Nutri-Body® Analysis” form. Complete it as instructed in it (it will take only 20 o 30 minutes of your time), and send it back to me by mail, or scan it and send it to my e-mail. The complete evaluation and my recommendations will be sent to you by e-mail and regular mail.

Fees:

My services are FREE of charge you will just pay for the supplements and shipping.

You will be contacted by e-mail by “PayPal” for credit card payment.

You can start now.

Name *
Date.
Email *
Address *
City *
Province/State *
Zip *
Phone *
Fax *
Male/Female *
Date of birth.
Ocupation *
Fist Test *	Yes No
Date of Last Test *
What is the reason or concern for your evaluation? *
Are you taking any medications? Please list. *
Do you use over-the-counter medications? Please list. *
Do you have any known food, environmental, animal, or drug allergies? Please list *
Are you taking any vitamins or other food supplements? Please list *
Please list any illnesses with which you have been diagnose. *
Do you excercise? Explain. *
What are your main health concerns? *
Are you currently seeing other health practitioners such as chiroparactor, massage therapy, reflexology, homeopath, naturopath, etc..? *
Have you had any surgeries? What and when? *
Have you had any accidents? Explain. *
Do you have a family history of: Heart/circulatory problems; Diabetes; Cancer; Depression; Allergies; Osteoporosis. *
How many bowel movements do you have daily? *
Do you smoke? Have you smoked? If you quit, when? *
Do you have mercury amalgam fillings? How many? *
Have you had any dental problems? *
Have you had recent antibiotic treatment? When and for what? *
Have you ever had Candida (yeast infections)? *
Other fungal infections? *
Do you get colds or flus often? *
Do you have a childhood history of infections? (Ear, sinus, throat, urinary tract, kidney, etc...) *
Have you been exposed to toxic environmental substances? What and when? *
Are you on a special diet? *
Are there any foods you feel bother you in any way? *
List any foods you crave. *
Soft drinks, alcohol, fruit juices, milk, coffee, and tea. How much do you drink per day? *
How often you eat in restaurants? Eat raw foods? *
Do you feel tired or sleepy after meals?	Yes No
Any simptoms if you skip meals? *
How often do you eat bread and pasta and what kind is it? *
Detail 24 hours dietary recall. Breakfast, Lunch, Supper, and Snacks. *
Is there any thing you have experienced after which you could say your health has never been the same since? *
I would like to make the complete evaluation. *	Yes No

Gemma Gath, BASc, RNCP, CPCC
1702-1003 Burnaby St. • Vancouver, BC V6E 4
Phone: (604)568 9630 • Fax: (604)568 9631
Certified Professional Cancer Coach

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