Alkaline . Anti-inflammatory . Ayurvedic
Date of Birth
Date of Birth
For Female clients:
Are you Pregnant?
If yes, how many months?
Are you nursing?
Are you going through menopause?
Medical Diagnosis, please check off all that may apply:
High blood pressure
Gall bladder disease
List any injury or surgeries
Reason for your visit
Describe your Main Health Concerns and Complaints:
Food Allergies or Intolerances:
Do you Smoke?
How many drinks per week?
How many cups of coffee per day?
More than Two
How many cups of Water per day?
Have you experienced recent:
If yes, please elaborate:
Have you tried to lose weight in the past?
If yes, # of pounds:
How much of this weight did you gain back?
In how long?
Do you feel your eating is out of control? How so?
Who prepares meals & shops:
Eats out how many days per week?
Describe your Appetite:
Describe Any Dietary Restriction, such as No Meat, No Dairy, etc:
Do you Experience Recurring Cravings? What Do You Usually Crave and at What time of the Day?
Physical activity habits:
How long and how often:
Most of the time what’s your stress level on a scale of 1-10?
What do you hope to take away from this session?
What barriers or obstacles will challenge you reaching your goal?
Lack of nutrition knowledge
Lack of time/hectic schedule
Emotional eating (overeating or not eating enough due to stress, boredom, anxiety, loneliness, being scared, sad, happy)
Don't like to cook
Don't know how to cook
What are the foods and beverages items that are always around in your pantry or fridge/freezer in your house (because you use them frequently):
How is Your Breakfast Like? Please be specific by listing what and the time you usually eat.
How is Your Snack Like? Please be specific by listing what and the time you usually eat.
How is Your Lunch Like? Please be specific by listing what and the time you usually eat.
How is Your Dinner Like? Please be specific by listing what and the time you usually eat.
Check the answer that best applies to you:
I plan meals for the week
I plan meals 1-2 days ahead of time
I plan dinner at breakfast time
I plan dinner on the way home from somewhere
I drop into the store and then figure out what to eat
For the most part, I don’t plan at all and just grab whatever I am in the mood to eat
I fully discharge Anamaria Pontes from any responsibilities or liability arising from my participation in any of the services or instruction provided by her. I understand that the instructions and/or services are not medical treatments, and no diagnosis will be made. Anamaria’s services are therapeutic, yet they are not replacement of any physician’s care when indicated.
Please add your initials if you agree