Dr. Cory - registration

Personal Information

Name

Date

Sex

Male Female

Birthdate

Age

Height

Weight

Address

City

State

Zip

Contact

Home Phone

Work Phone

Health Information

Please list any current health conditions,
including diseases and illnesses.

Are you presently being treated by a
physician for the above conditions?

Yes No

If yes, please list the physicians and reason for treatment.

Have you lost or gained a significant amount
of weight (25 lbs. or more) in the last year?

Yes No

What do you consider your ideal weight?

When was the last time you
were at your ideal weight?

If overweight, what do you perceive as your
greatest barrier to weight loss?

Please list any prescription or over the counter medications you are currently taking. Please include dose and reason for taking this medication.

Please list all supplements (herbal, homeopathic, or nutritional) you are currently taking.

Health History (cont)

Please explain in detail any listing that you marked above

Are any of these conditions currently active?

Do you have any special dietary
considerations or food allergies?

overt food allergy low grade food intolerance

Please list those foods not tolerated and symptoms associated with your reactions.

Have you ever had liver or gall bladder issues in the past? If so, please describe.

Please list your goals for doing this cleanse:

Physical Goals:

Mental/Emotional Goals:

Spiritual Goals:

What sort of support network (family, friends) will you have during the cleanse?

What particular challenges do you expect to face during the cleanse?

Are there any habits you know you need to change to regain your health?

Do you have any special needs, concerns or fears about doing this cleanse?

By clicking submit I acknowledge that I understand the Essential Cleanse Program is an educational course and is not meant as a prescription for any general or specific health condition, or as a substitute for one-on-one medical advice and/or care from a duly licensed physician.

Certain individuals or other health care authorities may disagree with the opinions taught in this program.