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Orientation Form

Form Introductory Text

Personal Information

First Name*

Last Name

Date of Birth*

Street Address, House number etc*

Landmark, Floor, c/o

City*

Country*

State/Province*

Zip/Postal Code*

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Phone* ✓ Valid

Email Address*

Height*

Weight*

Sex*

Blood Type

Body Information

Body Systems Questionnaire*

Abdominal pain or discomfort Absent-mindedness or forgetfulness Acid indigestion or heartburn Anxiety, nervousness or tension Asthma Bad breath or body odor Brittle fingernails Burning or painful urination Cold hands and feet Colitis or other bowel irritations Congested air passages Constipation or dry stools Cravings for fat or high fat diet Cravings for sugar Dark circles or puffiness under eyes Difficulty getting to sleep Dizziness or light headedness Dry Skin Excess mucus production Family history of heart disease Fatigue in the afternoons Fatigue or low energy levels Food allergies Food sits heavy on stomach after eating Frequent backaches Frequent cough Frequent infections Frequent urinary tract infections General weakness or chronic illness Hayfever Heart problems High blood pressure High cholesterol Impotency (males only) Infertility Intestinal gas or bloating Itchy nose and ears Joint pain, arthritis or gout Leg cramps or pains Less than 1 bowel elimination per day Loose stool or diarrhea Loss of appetite or poor appetite Loss of sexual desire Menopause problems (females) Menstrual problems (females) Mental / emotional stress Migraine headaches Muddled thinking, confusion or sluggishness Osteoporosis Pale complexion and/or anemia Prostate problems (males) Restless dreams or nightmares Scant or excessive urination Sinus congestion Sinus headaches Skin problems (acne, rashes, etc.) Stiff, aching, or painful muscles Swollen lymph glands Ulcers Underweight or unable to gain weight Urinating at night Varicose veins Waking up frequently at night Water retention or edema Weak legs, knees or ankles Wheezing or shortness of breath Wounds won't heal on extremities, i.e. arms, hands, legs, feet

Lifestyle Habits

How much water do you drink each day?*

What type of water do you drink?*

Briefly describe your current eating habits.*

What nutritional supplements are you currently taking?*

What prescription medications are you currently taking?*

If you could improve 3 things about your health, your body, or how you feel, what would they be?*

Additional Comments / Questions*

Living Balance Wellness was founded with a mission to transform health and wellness in Boston and the surrounding areas.

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32 Rockway Ave, Weymouth, MA 02188, United States

(781) 492-5720

livingbalance180@gmail.com

Home
About
Services
FAQ
Lab Testing
Designs For Health
- Exclusive Discount Code: Gut7 – Click Here to Save!
Nutrafol
Store
Blog
Service Areas
- Service Areas
- Weymouth
- Boston
- Needham
- Wellesley
- Newton
- Hingham
- Norwell
- Hanover
- Rockland
- Cohasset
Contact