Name Date

How is your overall energy?

How many bowel movements do you have per day?

What color are they? Are they formed?

What is your daily water intake since your last visit?

How have you been doing on your diet, have you been eating the proper foods?

How have you been sleeping?

What is your stress level on a scale of 1-10? (1 bad, 10 good)

How are you handling your stress level?

At what percent did you take your nutritional program?

Did you have everything you needed for your program?

What was the most positive change during the last month on your program?

Which of your problems did not change?

Did you have any difficulty when taking any of your supplements?

What problem is still your top concern that should be addressed in today’s session?

List your medications:

Have there been any medical treatments since your last visit? If so, please list
each incident.