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 or to register for our New Patient Workshop.
Call: 480-659-0748
Email: info@smartnutritionbykg.com