Intake Form

Please complete in its entirety prior to sending in your hair sample. Please plan for approximately 30 minutes to fill out the form. Your answers are completely confidential.

Name *
Name
Phone *
Phone
Address *
Address
in lbs
DIet
Now we will take a look at your typical diet. Please list your typical foods for each meal below. Include anything you consume at least once per week.
List foods and beverages.
List foods and beverages
List foods and beverages.
List foods you consume between meals.
What do you eat when you crave something sweet?
If so, please list the diet.
Please list foods or food categories you do not eat and describe why.
Lifestyle
Let's discuss your lifestyle and habits.
Include frequency, duration and type of exercise.
Please check the types of alcohol you drink *
If so, please list the kinds used and frequency
Date for Signature *
Date for Signature
Signature *
Signature
By typing your name here, you are digitally signing this form and indicating that you understand the following: Nutritional Balancing is a means to reduce stress and balance body chemistry. It is not intended as diagnosis, treatment or prescription for any condition or disease. Kelly Storrs holds a certificate in Nutritional Balancing Science and works as an unlicensed Nutritional Counselor.