GENERAL INFORMATION SHEET LAB # (if assigned) __________________

Name_______________________________________ Age____ Sex: M F Date_______________

Address________________________________________________________________________
City_____________________________ State/Prov.______________________ Zip____________
Home Phone_________________________ Business Phone______________________________
E-Mail Address__________________________________ Height________ Weight____________
Occupation____________________ How were you referred?_____________________________
What are your main health concerns or conditions?_____________________________________
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Please list any medications or food supplements you are currently taking:
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Please list any recent medical tests results you have, such as blood tests:
______________________________________________________________________________
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Please list illnesses in your family such as heart disease, cancer, TB, diabetes or
arthritis._______________________________________________________________________
DIET: What are examples of typical breakfasts for you? Beverages
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Mid-morning Snacks________________________________________|_____________________
What are typical lunches for you? Beverages
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Mid-afternoon Snacks________________________________________|____________________
What are typical dinners for you? Beverages
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Evening Snacks______________________________________________|___________________
How often and what kind of exercise do you do?_______________________________________
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About how many hours of sleep do you get per day?___________________________________
I understand that nutritional balancing is a means to reduce stress and balance body chemistry and that Eileen Durfee is
providing services as a Nutritional Balancing and Lifestyle Coach and is a Minister with a Diploma in Nutritional Balancing
Science, doing business as Go Healthy Next. Testing and consultations performed are not intended as diagnosis,
treatment or prescription for any condition or disease.

Signed____________________________________ Date____________

____________________________ SYMPTOMS SHEET CIRCLE any conditions or symptoms that presently describe you.
Printed Name
PLACE A STAR next to the symptoms most important to you.
Kidney Stones
Acne
Joint Pain
Water Retention
Eczema
Joint Stiffness
Sinus Headaches
Fungal Infections/Candida
Arthritis, Osteo
Tension Headaches
Psoriasis
Arthritis, Rheumatoid
Hives
Muscle Pain
Migraine Headaches
Hair Loss
Muscle Weakness
Neuritis
Slow Wound Healing
Muscle Cramps
Eye diseases
Cataracts
Bursitis
Constipation
Glaucoma
Fractures
Diarrhea
Meniere's
Disease
Osteoporosis
Intestinal Gas
Tooth Decay
Gout
Bloating
Excessive Plaque on Teeth
Sweet Cravings
Heartburn
Gum Disease
Sugar Reactions
Ulcer
Infections/Viruses
Irritable before meals
Stomach Pain
Tumors/Cancer
Can't Skip Meals
Colitis
Multiple Sclerosis
Hypoglycemia
Gall Stones
Parkinson's Disease
Crave Starches
Fissures
Scleroderma
Fat Cravings
Hemorrhoids
Anger
Other Food Cravings
Cirrhosis
Anxiety
Food Allergies
Diverticulitis
Bipolar Disorder
Excessive hunger
Tend to Gain Weight
Brain Fog
No hunger
Tend to Lose Weight
Confusion
Diabetes
Anemia
Depression
Rapid Heart Rate
Easy Bruising
Irritability
Skipped Heart Beats
Drug Addiction
Mind Races
Heart Palpitations
Alcoholism
Mood Swings
Heart Attack
Smoking
Obsessive/Compulsive
Poor Circulation
WOMEN:
Panic Attacks
Dizziness
Premenstrual Syndrome
Poor Memory
Low or High Blood Pressure
Water Retention
Schizophrenia
Angina
Cramps
Trouble Sleeping
Arteriosclerosis
No Menstruation
Autism
High Cholesterol______
Heavy periods
Attention Deficit
High Triglycerides____
Light/Irregular Periods
Hyperkinesis
Cough
Ovarian Cysts
Dyslexia
Bronchitis
Fibroid Tumors
Seizures
Asthma
Abnormal Pap Smear
Learning Disability
Post-nasal Drip
Menopause
Mental Retardation
Sinus Congestion
Fibrocystic Breasts
Delayed Development
Allergies
Breast Tumors
Bladder Infections
Emphysema
Yeast Infections
Kidney Infections
Fatigue
Hot Flashes
Trouble Urinating
Hypothyroidism
MEN:
Frequent Urination
Low Body Temperature
Prostate Problems
Painful Urination
Cold in Winter/Dry Skin
Impotence
Kidney Stones
Tend to Gain Weight
Infertility
Water Retention
Hyperthyroidism
Other Symptoms or Comments:
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