Candida Cleansing
Health Questionnaire - Free Consultation
We are interested in using the information you provide us to create a nutritional
health program that will address your goals in relieving Candida. All information
will be held confidential.
*
Required Field
Your name:
*
Email:
*
*
Phone:
W:
H:
Charlotte Carreira
Wellness Coach
Best times to call & time zone:
(preferred)
Weight: (actual)
Height
Please rate level of Candida you believe you have
(1=low tolerable 10=:High severe impact on life)
Have you been diagnosed by a doctor?
No
Yes
Completed a lab stool test?
Yes
No
Rate your overall health (1= poor to 10=excellent)
hrs. per night
Sleep:
Water intake:
oz per day
# of glasses or
Bowel movements per day:
Are they:
easy
medium
strained?
Under medical doctor's care now?
Yes
No
Yes
Current chiropractic care:
How often?
No
No
What type?
Other body work?:
Yes
Please check all that apply
Prescribed medications
Please list:
Antibiotics
Last time antibiotics taken:
No
Yes
Birth control pills
Have you taken in the past?:
Over the counter medications:
Please list:
Supplements:
Type:
For how long and did you smoke in the past?
Smoke cigarettes:
Weight / Health program:
Type:
Amount / type of exercise program you do:
Type of diet, in general:
What are your favorite foods?
Do you use/ consume any of the following (check all that apply):
Coffee or black tea
How much?
cups per day
Alcohol
glasses per week
How much?
Carbonated beverages
What kind?
How much?
What type?
Artificial sweetners
Like salty type foods?:
Add salt to meals
Yes
No
Fast Foods
(Burger
King. McDonalds, etc. )
How often per week?
Poultry
Fish
Meat
Canned food
Prepared/frozen food
Fresh vegetables
Fresh fruits
Organic
%
% versues Non-organic
Please check any of the following that apply to you:
Skin problems
High blood pressure
Constipation
Diarrhea
Hypoglycemia
Thyroid problems
Diabetes
Cholesterol
Headaches
ADD/ADHD
Depression
Insomnia
Stress
Allergies
Lack of focus
Weight issues
Stomach/intestinal gas
Low energy
Overwhelm
PMS/Menopause
Other.
Please describe:
Indigestion
Heartburn
Complete the following:
Values (What is important in your life?):
Fun, Hobbies & Recreation:
Regular spiritual practice?:
Yes
what type?
No
Please rate your Level of Commitment to eliminating Candida:
1 = low, “I KNOW I SHOULD, don’t really want to; my spouse, etc. wants me to…”
10 = very high, “Definitely, I’ll do what it takes….”
Are you willing to commit to a
6-month program with coaching?
Yes
No
Why not?
Other comments:
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