Rose Nutrition Center

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PERSONAL HISTORY AND PROFILE

Please complete the form below (allow approximately 5 minutes) and click the submit button in order to receive a consultation. If you prefer, this form may be printed and faxed or mailed.

RoseNutrition.com and Rose Nutrition Center respects your privacy. We will not disclose your individual identity or personally identifiable information without your prior consent except as required by law, court order, or as requested by other government or law enforcement authority. Please read our Privacy Policy.

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PART 1 - GENERAL INFORMATION

Last Name:

First Name:

E-Mail Address:

Daytime Telephone (Optional):

Age:

Height:

Weight:

Desired Weight:

Occupation:

Gender:

Male Female

PART 2 - LIFESTYLE INFORMATION

Do you smoke?

Yes No

If yes, how many years?

If yes, When did you quit?

How much exercise do you get?

less than 3 days per week
3-5 days per week
5-7 days per week

Duration of exercise:

less than 30 minutes per session
between 30 and 60 minutes per session
more than 60 minutes per session

How many hours of sleep do you
get each night?

Less than 6
Between 6-7
Between 7-8
More than 8

How stressful do you percieve your life to be?

Extremely Stressful
Moderately Stressful
Not Stressful

How often do you eat in restaurants?

More than 7 meals a week
3-7 meals a week
Less than 3 meals a week

PART 3 - PHYSICAL HEALTH

Do you currently have, or have you had in the last 5 years, any of the following conditions:

Surgery (Explanation)

Other (Explanation)

Do you think you have ever been "addicted" to any of the following?

Alchohol	Sugar
Marijuana	Junk Food
Caffeine	Cocaine
Tobacco	Other (Explain)

Other (Explanation)

Do you experience bloating or discomfort after eating?

	No or Rarely: You have never experienced the symptom, or you have experienced it and perceive it to be insignificant
	Occasionally: Symptom comes and goes, but is linked to stress or some other identifiable trigger
	Often: Symptom occurs 2-3 times per week, or enough to bother you
	Frequently: Symptom occurs 4 or more times per week and/or on a regular basis

Does your energy ebb and flow during the day?

	No or Rarely: You have never experienced the symptom, or you have experienced it and perceive it to be insignificant
	Occasionally: Symptom comes and goes, but is linked to stress or some other identifiable trigger
	Often: Symptom occurs 2-3 times per week, or enough to bother you
	Frequently: Symptom occurs 4 or more times per week and/or on a regular basis

Do you experience reflux or heartburn after eating?

	No or Rarely: You have never experienced the symptom, or you have experienced it and perceive it to be insignificant
	Occasionally: Symptom comes and goes, but is linked to stress or some other identifiable trigger
	Often: Symptom occurs 2-3 times per week, or enough to bother you
	Frequently: Symptom occurs 4 or more times per week and/or on a regular basis

Do you get agitated or lightheaded if you miss a meal or go too long without eating?

	No or Rarely: You have never experienced the symptom, or you have experienced it and perceive it to be insignificant
	Occasionally: Symptom comes and goes, but is linked to stress or some other identifiable trigger
	Often: Symptom occurs 2-3 times per week, or enough to bother you
	Frequently: Symptom occurs 4 or more times per week and/or on a regular basis

How many bowel movements do you have each day?

2 to 3
1 to 2
1 approximately every other day
1 every two or three days or irregular

What is your first health goal?

What is your second health goal?

Are you currently taking any over-the-counter or prescription medications? (Please list)

PART 4 - CONSULTATIONS

What type of consult are you interested in?

Initial Consultation
Basic Phone Consultation (15 minutes)
Half-hour Phone Consultation
Half-hour Phone Consultation with Chemistry

PART 5 - AGREEMENT

Agreement to the following is mandatory to receive a consultation and Personal Nutrition Program.

I understand that any suggested program I may receive from Rose Nutrition Center has been prepared, at my request, solely for the purpose of providing nutritional education. Any suggestions made by Rose Nutrition Center relating to nutrition, including herbs, vitamins, minerals, juices, food supplements, teas and food in general, are not to be interpreted or construed as a "diagnosis" in any manner whatsoever. In the event that I use this information without supervision or approval of a medical doctor, I may be "prescribing" for myself, which is my constitutional right, but for which Rose Nutrition Center assumes no responsibility. Therefore, this information is offered without any claims as to what it may or may not do. I further understand that this is a suggested program and is strictly voluntary. If I follow it, I do so according to my own will and at my own risk.

I agree to the foregoing