Cansultation form to fill for Patrick to help you with your ailment

Consultation form

Please fill the following consultation form.

Patrick will contact you shortly to let you know when your consultation will be ready.

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

E-Mail Address*

Country*

Phone number*

Which is your favorite method for the consultation?*

	WhataApp
	Skype
	FaceTime
	Messenger

Gender*

	Female
	Male

Date of Birth*

Weight in kilograms*

Height in centimeters*

What is your MAIN health concern?*

Any other health problems?*

What medication(s) are you taking?*

What vitamins/ herbs are you taking?*

Do you exercise? Which, and how often?*

How much stress are you under?*

	Little
	Medium
	A lot

How many coffee, or caffeinated tea, do you drink every day?*

	1
	2
	3
	4
	5
	6
	More than 6

How ofen do you eat chocolate?

	Daily
	2 or 3 days a week
	Almost daily
	Rarely
	Never

Do you eat any organic foods? Which and how often?*

I eat tropical fruits (oranges, bananas, kiwi, mangoes, etc..)*

	Daily
	Almost daily
	2 or 3 a week
	Rarely
	Never

How often do you eat seeds, nuts, avocados, hummus, coconut flesh or milk, or other oily products?*

	Daily
	2 or 3 a week
	Almost daily
	Rarely
	Never

I use oil for frying or in salad*

	Daily
	2 or 3 times a week
	Almost daily
	Rarely
	Never

I eat eggs*

	Daily
	2 or 3 days a week
	Almost daily
	Rarely
	Never

I eat fish or other sea food*

	Daily
	2 or 3 days a week
	Almost daily
	Rarely
	Never

I eat dairy products from cow, goat, sheep, Ghee, etc..*

	Daily
	2 or 3 days a week
	Almost daily
	Rarely
	Never

I eat gluten products such as bread, cakes, biscuits, flour products, pasta, or grains (except quinoa, millet, brown rice)*

	Daily
	2 or 3 days a week
	Almost daily
	Rarely
	Never

I eat chicken*

	Daily
	2 or 3 days a week
	Almost daily
	Rarely
	Never

I eat beef*

	Daily
	2 or 3 days a week
	Almost daily
	Rarely
	Never

I eat tin food or pre-prepared meals*

	Daily
	2 or 3 days a week
	Almost daily
	Rarely
	Never

Other meat you eat*

I always check products labels to make sure I don't eat chemicals, sugar, etc.*

	True
	False

smoke*

	True
	False

I drink alcohol*

	True
	False
	Rarely

f you have only recently changed your diet to the above. Please state when you changed it, and what your previous diet was*

How did you hear about my consultation?

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