First Name
Last Name
E-mail
Phone
Mailing address
Date of birth
Age
Weight in lbs.
Height in inches
Waist circumference in cm.
Please describe what you are looking to achieve health-wise by way of my services.
Have you been diagnosed with any medical conditions by a doctor?
Are you currently taking any medications? If so, which?
Are you currently taking any dietary supplements? If so, which? Please be specific by listing brand names, chemical formulations, and dosages. Or, if possible, paste links to the specific supplements on a website like Amazon or iHerb.
How many times a day do you eat?
Do you fast? If so, please describe your fasting schedule.
How often do you eat meat (red meat, white meat, seafood, eggs, etc.)?
Please describe what foods you typically eat, what snacks you eat, and what drinks you drink and how often you drink them.
How often do you cook at home versus go out to restaurants to eat?
What fats/oils do you cook with?
How much sleep do you typically get? Would you say it is good quality sleep?
How much sun exposure do you typically get in the summer and in the winter?
How would you rate your typical stress level?
Is your lifestyle busy, slow, very athletic, sedentary, etc.?
Please check all of the following symptoms you have experienced within the past 6 months:
How long have you had the symptoms you marked off?
Have you had any other issues in the past 6 months worth noting?
Have you had 23andMe or another company analyze your DNA?
How did you hear about me / Elusive Iron?
Any further comments?
Once you submit this form, you will be sent to a page where you can upload blood test results if you have any.
I will then review all your information and reply to you in the next few days.
Thank you!
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