Client: Doctor:   Insurance/Facility:
Address: Address:   Address:
email: email:   email:
Telephone number: Telephone number: Telephone number:
Date:    Notes 
Age:    
Height:    
Weight:    
Sex:    
Favorite Activity:    
Nutrition    Notes 
What type of meals or meal plan do you enjoy?    
Do you Cook?    
Who prepares your meals?    
Last three days meals?    
Food Allergies?    
Weight History?    
Activities Current  Goals   Completion   Notes 
Do you currently do any activity?        
How many minutes per week?        
         
         
LEVELS Current  Goals   Completion   Notes 
     Blood Pressure        
     BMI        
     BMR        
     Alkalinity        
A1C        
Heart Rate        
Sleep hours per day        
Glucose        
Blood Oxygen        
Nutrition / Calorie intake per day        
Favorite Activity        
         
       
         
  Yes  No  Maybe Notes
DNA Test        
Genomic Nutrition Plans        
Genomic Activity Plans        
Meditation Plans        
         
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