Step 1

Before we meet with you, we will need to obtain some information about you. Please complete and submit the form below. We must receive this before our first visit with you.

     

    Were you ever diagnosed with an eating disorder? YesNo

    Were you ever diagnosed with the following or take medication for these conditions?

    High Cholesterol: YesNo

    High Blood Pressure: YesNo

    Diabetes Type I or II: YesNo

    Prediabetes: YesNo

    Coronary Heart Disease: YesNo

    Heart Failure: YesNo

    Renal Disease: YesNo

    Thyroid: YesNo

    Reflux/Gerd: YesNo

    Migraines: YesNo

    PCOS: YesNo

    Asthma: YesNo

    Anxiety: YesNo

    Depression: YesNo

    Sleep Apnea: YesNo

    Do you use tobacco products: YesNo

    Do you use medical marijuana: YesNo

    Celiac Disease: YesNo

    Tested for Celiac Disease: YesNo

    IBS: YesNo

    Ulcerative Colitis: YesNo

    Crohn’s: YesNo

    Gas: YesNo

    Bloating: YesNo

    Constipation: YesNo

    Diarrhea: YesNo

    Cramps: YesNo

     

    Would like weight loss: YesNo

    Step 2

    E-mail or call us to make an appointment. We look forward to hearing from you soon!
    Call: 480-659-0748
    Email: info@smartnutritionbykg.com