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Coconut Paleo Wraps
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Orientation Form

First Name

Last Name

Date of Birth

Street Address

City

Zipcode

Phone

Email Address

Height

Weight

Sex

Blood Type

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) symptoms list 2 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

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

Gluten Free Options

Coconut Paleo Wraps

Start to take control of your health by filling out your orientation form.

Orientation Form