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Client Information Form

For Down 2 Hearth Consultations

All fields marked * are mandatory. Please enter NA if not applicable.


CURRENT SITUATION *


CURRENT MEDICATIONS


 

PAST HISTORY


FAMILY HISTORY

DAILY SCHEDULE

DAILY MEAL PLAN


 

CONSENT FOR TREATMENT THROUGH THE NEW LIFE PROGRAM- NUTRITION & LIFESTYLE CHANGES

I have given all the information pertaining to my health and have not hidden anything important from Vinita Contractor, Holistic Nutritionist & Lifestyle Coach. During the consultation my present condition, its cause and how I can reverse or improve it will be explained to me. I will also be explained the nutrition regime that I shall have to follow to benefit from the consultation. I understand that this is a lifestyle that I will have to continue in order that my disease, once gone will not return. I understand that with this method I have to take responsibility for my health, and that regular lab reports may be necessary to be sure that the improvement is occurring and to enable reductions in medications.

I understand that I will be given a nutritional regimen and will be told what improvement I can expect. Following the nutritional regimen as prescribed is intrinsic to reversing / improving my conditon. I do take full responsibility of my own health. I will also be suggested lifestyle changes. I understand that I should inform doctor if ever my health takes a turn for the worse. I understand that each individual and their disease is unique. I will not blame Vinita Contractor or Down 2 Hearth if I do not get cured of my disease or if I do not take professional medical advice where needed.

I agree to follow the recommended suggestions if I want to get the results through nutrition and lifestyle.



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'Counting calories becomes completely unnecessary when your food doesn't come with labels.'