d'auria esthetics & wellness

HOLISTIC NUTRITION CONSULTATION

ALL INFORMATION IS CONFIDENTIAL

Name

Date

Address

Phone

Whom may we thank for your referral?

Sex

Age

Birthdate

Height

Weight

What medical concerns (e.g., pregnancy) if any, do you have at this present time?

Do you use tobacco in any way? If so, how much?

Did you recently stop smoking?

Do you enjoy physical activity? Please explain

List any food allergies or intolerances.

List any prescribed, over-the-counter, herbal, or vitamin/mineral supplement you take.

Do you follow a special dietary plan, such as, low cholesterol, kosher, vegetarian?

Have you ever followed a special diet? Explain.

Are there certain foods that you do not eat?

Do you eat at regular times each day?

Yes

Identify any foods you particularly like.

Do you drink alcohol? If so, how often?

Please add any additional information you feel may be relevant to understanding your nutritional health.

Are you employed? If so, what's your occupation?

Do you use convenience foods daily?

Yes

How often do you eat out? Where?

Informed Consent Agreement

I give consent to D’Auria Esthetics and Wellness to provide Nutrition Counseling to myself or the client for which I am legally responsible. The consult will provide information regarding my health, lifestyle and diet.

I understand that Alexandria D’Auria is a certified Holistic Nutritionist and certified Health and Wellness Coach and not a medical physician. Thus, she will not diagnose medical conditions, but will provide nutritional support and nutrition education. I understand these services are not a substitute for medical care. Methods of nutrition counseling made available to me are not intended to diagnose disease.

I have read this consent form and terms contained herein carefully. I understand the terms of this form fully and voluntarily agree to be bound by them.

Your Signature

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