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Evaluation Form -Admin

Bloodwork

Choose File
Choose File

Please indicate foods you dislike by checking the boxes below

Meat:
Nuts/Seeds:
Eggs & Poultry:
Legumes:
Fish:
Breads/Rice:
Fats:
Fruit:
Miscellaneous
General:
Vegetables:
Do You Have the following Equipment?
Salads:

Please indicate foods you are allergic to by checking the boxes below

Meat:
Nuts/Seeds:
Eggs & Poultry:
Legumes:
Fish:
Breads/Rice:
Fats:
Fruit:
Miscellaneous
General:
Vegetables:
Salads:

Food Journal

You must fill every field.  If the field does not apply to you, please type N/A

Day 1

Day 2

Day 3

Day 4

Medications & Supplements

Contact Information

Healthcare Providers (doctors, dentist, naturopath, chiropractor, etc.)

Standard Disclaimer

We recommend that you inform your Doctor regarding any new nutritional program, exercise program or nutritional supplements.

While your treatment at EarthSuit Nutrition may dramatically reduce your need for your current prescription drugs and their dosages, EarthSuit Nutrition does not recommend or suggest or imply that you discontinue or alter the use or dosages of any Doctor-recommended prescription medications, without the consent, supervision or recommendation of your Doctor.

Each client at EarthSuit Nutrition has a Meal Plan designed specifically for them which takes into consideration their individual goals, objectives and nutritional requirements. EarthSuit Nutrition therefore, does not recommend the sharing or distribution of your meal plans to others.

Deposits will not be refunded for cancelled appointments or appointments rescheduled with less than 48 hours notice. Deposits are non-refundable and non-transferrable for unused or cancelled program sessions.