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Contact Information

Fields marked with an asterisk (*) are required.

Full Name:
Email:
Address:			City:
State:			Zip:
Phone:

Age:			Birthdate:
Height:			Weight:
Reasons for consultation and/or goals:

How many times do you usually eat per day?

Please recall your last 3 full day's meals, snacks, and drinks

Day 1:

Day 2:

Day 3:

Do you smoke? If so, how many per day/week/month

Do you drink alcohol? If so, what type and how often? Per day/week/month

How often do you drink coffee? Per day/week/month

How often do you have soft drinks? Per day/week/month

Do you overeat? If so, which foods and how often?

Do you have any food allergies, restrictions, or sensitivities?

Do you get noticeably irritable, lightheaded, or weak if you haven't eaten in a while?

Please list any food aversions and/or foods you dislike:

How often do you eat at home/cook your own meals? Per day/week/month

Do you crave any of the following frequently?

  Sweets / Desserts
  Chocolate
  Diet Sodas
  Bread / Pastas
  Meat
  Fish
  Milk or Cheese
  Fried Foods
  Peanuts
  Alcoholic drinks
  Other:

Which oils do you use/consume?

  Butter
  Margarine
  Extra Virgin Olive Oil
  Coconut Oil
  Flaxseed Oil
  Hempseed Oil
  Sesame Oil
  Peanut Oil
  Corn Oil
  Crisco
  Udos Choice Oil
  Vegetable Oil
  Soybean Oil
  Canola Oil
  Sun/Safflower Oil
  Mayonnaise
  Other:

How is your dental health?

What is your blood type?

How often do you have bowel movements? Per day/week/month

How often do you urinate? Per day

Are your nails weak or brittle?

Rank the condition of your skin without lotion:

  Very Dry
  Dry
  Normal
  Oily
  Combination

Rank the condition of your hair:

  Very Dry
  Dry
  Normal
  Oily
  Dandruff

Please check off any of the following that pertain to you (recent, past or present):

Acne/blemishes
  Addiction (alcohol, drugs)
  Anemia
  Anorexia
  Anxiety
  Arthritis (Rheumatoid or Osteo)
  Asthma
  Bladder infections (Cystitis)
  Blood Sugar problems
  Bronchitis
  Cancer
  Candida
  Colds or flu (frequent)
  Cold Sores
  Chronic fatigue
  Dandruff
  Depression
  Diabetes I (insulin dependent)
  Diabetes II (adult onset)
  Difficulty losing weight
  Difficulty gaining weight
  Emotional problems
       (instability or sensitivity)
  Emphysema
  Fainting
  Fibromyalgia
  Gout
  Hair loss or poor hair growth
  Headaches

Heart disease
  Herpes type I mouth/face
  Herpes type II genital
  High blood pressure
  High cholesterol
  HIV
  Hot flashes
  Hypoglycemia
  Insomnia
  Kidney stones
  Lupus
  Memory loss or confusion
  Menopausal symptoms
  Migraines
  Nails, poor growth
  Nails, white spots
  Panic attacks
  Pregnant or nursing mother
  Respiratory problems
  Ringing in ears
  Seizures
  Severe mood swings
  Skin conditions
  Stroke
  Suicidal tendencies
  Thyroid condition
  Ulcer
  Yeast infections
  Other:

Women, please check any that pertain:

  PMS
  Urinary Tract Infections (UTI)
  Irregular periods
  Painful menstrual cramps
  Birth control pills
  Yeast Infections
  Low or decreased libido
  Menopause
  Painful intercourse
  Hysterectomy
  Fertility concerns

Men, please check any that pertain:

  Frequent Urination
  Difficulty urinating
  Difficulty with erection
  Low or decreased libido
  Prostate Enlargement
  Un-viable sperm/Fertility concerns

Do you exercise? If so, what kind, how often, and since when?

Do you take any nutritional supplements or vitamins? If so, which ones? (be specific)

Do you exercise? If so, what kind, how often, and since when?

Which prescription and over the counter medications do you take currently?

Have you ever done a cleansing fast? If so, when and/or how often?

Please list any disease, illness, or ailments in your immediate family(i.e. mother breast cancer, father-type II diabetic, grandfather, heart disease)

Rate you daily energy level:

  Excellent
  Good
  Fair
  Poor

Rate your energy level after exercise:

  Excellent
  Good
  Fair
  Poor

Rate your daily stress level

  Very High
  High
  Moderate
  Low
  None

Rate your enjoyment of life:

  Excellent
  Good
  Fair
  Poor

How much sleep do get on average each night?

Do you have any problems sleeping?

Please feel free to expand on any concerns you think are important/relevant to your health.

Are you willing to do fresh juicing?

Are you willing to make protein shakes?

Please check off any vegetables you will eat.

Alfalfa Sprouts
  Artichoke
  Arugula
  Asparagus
  Beans (black, lima, etc.)
  Beets
  Black eyed peas
  Broccoli
  Brussels sprouts
  Cabbage
  Carrots
  Cauliflower
  Celery
  Chard
  Chives
  Collard Greens
  Corn
  Cucumber
  Eggplant
  Endive
  Fennel
  Garlic
  Ginger
  Green Beans
  Kale
  Kelp

  Leeks
  Lentils
  Lettuce (romaine, baby greens, etc.)
  Mushrooms
  Mustard Greens
  Okra
  Onions
  Parsley
  Parsnips
  Peas
  Peppers (red or green)
  Potato
  Pumpkin
  Radicchio
  Radishes
  Rhubarb
  Rutabaga
  Spinach
  Squash
  Sweet Potato
  Tomato
  Turnips
  Water Chestnuts
  Yams
  Zucchini

Please check off the fruits you do like.

Apple
  Apricots
  Avocado
  Banana
  Blackberries
  Blueberries
  Boysenberries
  Cantaloupe
  Cherries
  Cranberries
  Dates
  Figs
  Grapefruits
  Grapes
  Guava
  Honeydew
  Kiwi
  Lemon

Lime
  Mandarin
  Mango
  Nectarine
  Orange
  Papaya
  Passionfruit
  Peach
  Persimmon
  Pineapple
  Plum
  Pomegranate
  Prunes
  Raisins
  Raspberries
  Strawberries
  Tangerine
  Watermelon

Please check off the meat or poultry you will eat.

Chicken
  Ham
  Beef
  Pork
  Turkey

Tofu
  Buffalo/Bison
  Ostrich
  Eggs

Please check off the Nuts you will eat.

Almonds
  Walnuts
  Brazilnuts
  Hazelnuts
  Macadamia Nuts
  Pecans
  Hemp Seeds

Chia Seeds
  Pumpkin Seeds
  Sunflower Seeds
  Almond Butter
  Cashew Butter
  Sesame Butter

Please check off the Dairy you will eat.

  Cheese
  Yogurt
  Cottage Cheese
  Whey Protein Powder (Smoothies)

Please check off the Fish and Seafood you will eat.

Salmon
  Tuna
  Cod
  Grouper
  Sea Bass
  Snapper
  Herring
  Mackerel
  Crab

Lobster
  Shrimp
  Mussels
  Oysters
  Tillapia
  Grouper
  Sole
  Flounder

I understand that NHTI’s nutritionists are not medical doctors or practitioners and I am not seeking medical diagnoses or treatment procedures. The services performed by NHTI’s nutritionists are at all times restricted to consultation on the subject of nutritional matters intended for the maintenance of the best possible state of nutritional health and do not involve diagnosing, prognosticating or treatment of disease. I am here on this initial and any subsequent visit/online consult, solely on my own behalf.

By clicking submit you agree to the above statement and terms of use on this website.

Here at Nutritional Healing we strive to carry products for optimal healthy living. If you are looking for relief from Fibromyalgia, Arthritis, Allergies, or Candida feel free to contact us to speak with our nutrition consultant. We carry many lines of nutritional supplements, as well as all natural spa products and natural bath and beauty products. We carry many types of aromatherapy packs with name brands such as BodySense and Sonoma Lavender. Our Naturally Tricia's Dead Sea Salts are great for de-stressing and easing aches and pains. We also carry Topricin to aid with pain relief. We also offer customized healthy gift baskets for all your gift giving needs. We carry a wide line of professional vitamins including brand names such as Xymogen Vitamins, Metagenics, Greens First, Pharmax, and Orthomolecular.

Biogenesis Nutraceuticals: GlucoBalance Bars: Chocolate Mint, Chocolate , Peanut Butter Crunch, Chocolate Mocha
Xymogen: Oncoplex, IGG 2000, Alamax CR, Immunotix 3-6, Fit Foods, GlutAloMine, OptiCleanse GHI
Designs for Health: PaleoBars/Paleomeal, Chocolate Coated
Berry, Vanilla Almond, Cocommune, Vanilla PaleoMeal - Whey Cool Protein
OrthoMolecular Products: D-Hist, K-Pax, Cardio B, Orthomega, Ortho Digestzyme, Ortho Biotic, Natural Zzz's, Vitamin D
X-iser ~ Burst Training
Metagenics: Ultra Meal, Ultra Clear Plus, Ultra InflamX, Ultra Clear Sustain
Pharmax: Frutol, HLC Probiotics, HLC Candaclear, Finest Pure Fish Oil, CandaClear Four, Four Pillars
Vitanica: Yeast Arrest (Boric Acid)
Crayhon Research: Brain Vibrance Supreme, GPC Hummingbird
Matcha Green Tea Powder: Matcha Organic Green Tea Powder
Sonoma Lavender - Natural Spa Products - Dead Sea Salt - Natural Bath and Beauty Products
Greens First - Miracle Greens - Deeper Greens - Macro Greens
Davinci Labs - Spectra Reds
Topricin - Arthritis Relief - Fibromyalgia
World Nutrition: Vitalzym
PureRest Organic Pillows - Organic Bedding
Range Kleen - Enameled Cast Iron