Your Health evaluation | I Cook You Serve

Today's date*

Your First Name*

Your Last Name*

Date of Birth*

Your address

Your preferred contact number

Second contact name

Second contact number

Please fill the box for any health conditions that applies to you:

Allergies
Amyotrophic lateral sclerosis
ASDV (vascular disease)
Blood disorders or anaemia
Calculi or gallstones
Chronic pain or fibromyalgia
Cancer, lumps, tumour
Chest tightness, shortness or breath asthma
Cold sores or herpes labialis
Common colds, viral infections, or flu
Contusions, bruises, burn or cuts
Constipation
Colon inflammation or colitis
Cystitis or urinary track infection
Dementia or Alzheimer’s
Diverticulitis
Dermatitis, psoriasis, or skin conditions
Excess body fat and obesity
Excess alcohol and hangovers
Exhaustion or chronic fatigue
Enteritis or Crohn’s syndrome
Hypertension or high blood pressure
Hypo- or hyper- thyroidism
IBS (irritable bowel syndrome)
Insomnia or sleeping disorders
Insulin resistance or diabetes
Joint problems, arthritis, or osteoporosis
Low immunity or recurrent infections
Lung infection or bronchitis
Menopausal symptoms
Migraines or headaches
Mood disorder or depression
Muscle cramping or aches
Otitis or ear infections
Parkinson’s. past seizures or neuro-motor disorders
Podagra, gout, elevated uric acid
Pregnancy or lactating
Recent accident or major operation
Sinus inflammation (sinusitis)
Stomach pain, heart burn or indigestion
Stomach ulcers
Thrust, fungal infections or candidiasis
Varicose veins
Other health conditions or symptoms

Your responsibilities:

1. To consult with a Medical Doctor or General Practitioner if you have filled one or more of the boxes before commencing a new nutritional program with Shannon Howe from I Cook You Serve.

2. To inform your Medical Doctor or General Practitioner about the Health Evaluation and which health conditions you have checked.

3. To talk with a Medical Doctor or General Practitioner about the kind of nutritional program you wish to commence on and to follow their advice. If my health changes so that you subsequently answer ‘’yes’’ to any of the Client Health Evaluation Ailments undertake to inform Shannon Howe immediately and to talk with a Medical Doctors or General Practitioner about the kind of nutritional program that you am on, and to follow the advice of the Medical Doctor or General Practitioner.

Please Confirm:*

I have read, understood and agree to the following 3 statements

1. I have read, understood, and completed the Your Health Evaluation

2. All questions have been answered to the best of my knowledge

3. I am happy to participate in a nutritional therapy program
Please check each of the 3 statements about before completing this form.

Your HealthEvaluation

Please fill in Your Health Evaluation

Your Health
Evaluation