Consultation Form

I thank you for booking my consultation.

In order for me to be precise with my recommendations to help you recover long term health please fill in the form below.

If you have recently made changes to your diet please tell me. I am mainly interested in your diet prior to the onset of your disease. If you have made changes recently, please specify so in the box supplied on this form.

Patrick

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

City

Country*

Gender*

Date of birth*

Height in centimeters*

Weight in kilograms*

Your Email address*

Your phone number including country code*

Are you on WhatsApp?*

	Yes
	No
	I don't know what this is

What is your MAIN health concern?*

Any other health problems?*

What medication(s) are you taking?*

What vitamins/ herbs are you taking?*

Do you exercise? Which and how often?*

Do you eat any organic foods? Which and how often?*

How much stress do you have daily?*

	1 - Very little
	2 - A bit but manageable
	3 - Quite a bit
	4 - A lot
	5 - Very stressed every day

How many cups of coffee do you drink every day?*

	Zero
	1
	2
	3
	4
	5 or more

I eat at least 3 vegetables daily for lunch and dinner*

	True
	False

I eat fruits (oranges, bananas, kiwi, mangoes, apples, pears, etc..)*

	Daily 1 or more
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat chicken*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat beef*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat pork*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

Other meat you eat*

I eat eggs*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat fish or other sea food*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

How many times a week do you use oil for frying or in salads?*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

Specify how many times a week you eat the following: avocados, nuts, seeds, coconut flesh, other oily food*

I eat gluten products such as bread or cakes or biscuits or floury products (i.e. pasta..) or wheat food *

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat chocolate or other sweets*

	Never
	1 to 3 a week
	4 or more a week

I eat dairy products from cow, goat, sheep, etc..*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat tin food or pre-prepared meals*

	Yes
	No

I always check products labels to make sure I don't eat sugar*

	Yes
	No

I always check labels to make sure I don't eat any harmful chemicals (additives, coloring, etc..)*

	Yes
	No

IMPORTANT: If you have only recently changed your diet from the above. Please state WHEN you changed it, and what your previous diet was?*

I smoke*

	Yes
	No

I drink alcohol*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

Other Comments*

How did you hear about my consultation?*

	Google search
	Other search engine
	Your YouTube movies
	Your Blog
	Word of mouth
	I have ordered from you before
	Facebook
	Twitter
	I can't remember