Do not hit the return key to go between the fields. Use the tab key.
Hitting the return key will cause the form to automatically send the
form incomplete. If this happens, hit the back button and start again.
When complete, hit submit at the bottom.

If you have technical difficulties, you can also copy/paste the
form, and the information you have filled out, to Word, and
e-mail it to info@theartoflivingwell.com


Revisit Form

 

Name   Date     

  What are your main concerns at this time?
 

    What positive changes have you noticed since your last appointment?

 

 

 Any changes with weight ?
How is sleep ?  

Constipation or diarrhea? .

How are your sugar cravings?

How are your energy levels?

How is your mood?

 

Are you cooking more ?

What foods do you crave?

How is your diet these days ?

breakfast
lunch
dinner
snacks
liquids

Any other comments?

Which of the following do you use, and how often (if applicable)? 

Tongue Scraper?    

 Hot Towel Scrub? 

 Hot Water Bottle? 

 

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