This form is for your own personal assessment at this point.

I am not here to give any diagnosis or treatment but to share information about nutrition.

   However, I am willing to share my (never-to-be-humble) opinion if you think it can be of value to you…

 

Eat 2 Heal

Evaluation Form:

Date________________

Name____________________________________________________________________

Age  ______________   Gender______________

…………………………………………………………………………………………………………..

Current Assessment:

pain/disease level – ________________________________________________________________________

activity/ energy level – _______________________________________________________________________

sleep patterns – ____________________________________________________________________________

current weight – (include changes over last 6 months) ___________________________________

…………………………………………………………………………………………………………………..

Goals:

pain/disease level – ________________________________________________________________________

acivity/ energy level – ______________________________________________________________________

sleep patterns – ____________________________________________________________________________

goal weight – _____________________________________________________________________

 

Current Lifestyle:

Diet:

1. How often and what do you eat that you think is toxic?_____________________________________________________________________________________________

_____________________________________________________________________________________________

2. How often and what do you eat that you think is good for you? _____________________________________________________________________________________________

_____________________________________________________________________________________________

Activity/Exercise:

  1. What is your preferred activity?_____________________________________________________________

2. How often do you do it?_____________________________________________________________________

3. How long do you do it? _____________________________________________________________________

 

 

 

Recommendations:

Write down eveything you eat, drink or take internally (food – drinks – medications – supplements – etc.) for a week.

Honestly evaluate your lifestyle:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Changes that need to be made:

______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

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