Rosanna's Macrobiotic Consultation Form
Name
Address
Day Telephone
Night Telephone
Email Address
Date of Birth
Age
Occupation
Marital status
Number of children
General complaints
Allergies: food, dust, pollen, mold, animal
Weak immunity: frequent colds, infections, etc.
Asthma
Skin: dry, loose, rashes, pimples, psoriasis, other
Fatigue or anemia
Common Aches and Pains
Headaches
Muscle cramps
Repetitive strain injuries (carpal tunnel syndrome)
Backaches
Arthritis
Rheumatism
Digestive
Diarrhea or constipation
Poor digestion
Hemorrhoids
Ulcers: stomach or duodenal
Colitis (irritable bowels)
Circulatory
Poor circulation (cold hands and feet)
High or low blood pressure
High cholesterol
Weight
Overweight
Underweight
Ideal weight
Reproductive and Urinary-Male
Frequent urination, day or night
Inflamed prostate
Lack of vitality or libido
Low sperm count
Reproductive and Urinary-Female
Urinary and bladder infections
Pre-menstrual symptoms
Vaginal discharge or dryness
Irregular or no menstruation
Menopausal symptoms
Stress and Blood Sugar
Stress
Hypoglycemia (low brood sugar)
Anxiety or panic attacks
Sleep problems
Lack of concentration and poor memory
Excessive sweet cravings
Mood swings
Depression
Irritability
Other Present Concerns
Past Health Problems
Are you currently receiving any medical or alternative treatments?
Do you cook?
Often
Occasionally
Infrequently
Do you cook with?
Gas
Electric
Microwave
Do you exercise?
Often
Occasionally
Infrequently
Type and frequency of exercise.
List your hobbies.
Please check the foods you have been
eating regularly (a few times a week).
Whole or cracked cereal grains
Whole grain products (breads, pastas, etc.)
Vegetable soups
Fresh vegetables, cooked
Fresh vegetables, raw
Beans
Sea vegetables
Fish
Nuts
Seeds
Fruit
Fruit juices, unsweetened
Vegetable oil
Herbal teas
Meat
Poultry
Eggs
Cheese
Other dairy foods
Refined flour products
Canned foods
Frozen foods
Sugar or honey
Chocolate or carob
Artificial sweeteners
Soft drinks
Spices
List your favorite foods.
Comments.