Omni - Natural Products,Inc.
Intake Form
Name
Email address
Phone number
Current history(ailments) please explain:
What is your past medical history ?
Medications or Supplements :
Are you currently under a Doctors care ?Please explain,please provide your Doctors name and ph.number.
Concern
Have you ever worked with a Nutritional Herbologist ?if so please explain.
Activity Level
How often do you exercise?
Eating Habits :breakfast,lunch,dinner,snack include favorite food &snack
What do you do to manage your stress?
What are your sleeping habits like?
Fluid Consumption based on 8oz.daily seervings :Water ,Juice ,Soda, Coffe & Alcohol .
Do you smoke?
Yes
No
If so how often?
Are you pregnant?If so how far along?
Do you experience headaches?
Yes
No
Do you suffer from fatigue?
Yes
No
Do you suffer from Allergies?
Yes
No
Do you suffer fro Varicose veins?
Yes
No
Do you suffer from flatulence(gas)?
Yes
No
How often do you have Bowel Movements?
2-4 times a day
1-2 times a day
once or twice a week
once or twice a month
Do you experience Body or Feet order ?
Yes
No
Do You experience Halitosis(bad breath)?
Yes
No
Do you suffer from Acne?
Yes
No
Do you have irregular or painful menstrations?
Yes
NO
Do you suffer from reacurrent yeast infections?
Yes
No
If so please explain.
Have you been in an accident or suffered any injuries in the past 2-3 years,if so please explain.
Do you have tension or soreness in a specific area?If so please explain.
Do you have numbness or stabbing pains anywhere?If so please explain.
Do you suffer from low back pain?
Yes
No
Have you had any recent or past surgeries I should know about?
How would you rate your current health?
Excellent
Good
Average
I need HELP
What is your GOAL?
Other,please be specific.
Are you commited to changing your life for the rest of your life?
Yes
 
 
By pressing  the send button you agree to be proactive with this program.Also by sending this is your signature,and by signing you understand this information is For educational purposes only.This information is not intended to diagnose, treat, cure, or prevent any disease.
 
Thank You for commitment
 
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