Are you taking any Vitamins(Supplements)?	Are you taking any medication?
Hospitalisation. When and what for?	Exercise History:
	Times per week:
Do you smoke? Yes No	Length of session:
Do you use Contraception? Yes No	Intensity (Hard, Light, Med)
What form?	Do you suffer from Premenstrual tension? Yes No
Do you suffer from Bloating? Yes No	Do you suffer from Menopausal problems? Yes No
Do you suffer from Diarrhoea? Yes No	Do you suffer from Candida? Yes No
Do you suffer from Swelling? Eyelids: Yes No Fingers: Yes No Ankles:  Yes No	Do you suffer from Constipation? Yes No
	Do you suffer from Colds? Yes No
Do you suffer from Sinusitis Problems? Yes No	If suffer from Colds, how often?
Are you Fatigued? Yes No	Any headaches?
Do you suffer from Allergies? Yes No	Joint or muscle cramps?
Do you suffer from Digestive problems? Yes No
Please describe the allergies and/or digestive problems.

Family History? High Blood Pressure: Yes No Liver Disorder: Yes No Coronary Heart disease:  Yes No Diabetes: Yes No Cancer: Yes No	Beverages? Wine? How much?  Filtered or tap water?  Coffee? How often?  Tea/Herb Tea  Juices
Appetite:	Doctors diagnosis:
Have you ever followed a diet programme? (If so, what types?)	What are your goals?
General daily eating habits and pattern Breakfast:  Mid Morning snack:  Lunch:  Mid Afternoon snack:  Dinner:  After dinner snack:

Please indicate which programme you would like to follow. Allow 2 to 3 days for response. 

Programme Price Order Detox Programme (7days) R300.00 Optimum Health Maintenance Programme R300.00 Blood Type Programme (Your blood type is essential) R300.00