Nutritional Therapy Reflection on Life and Change Your DetailsFirst Name*Surname*Date of Birth* Date Format: MM slash DD slash YYYYSex*MaleFemaleOccupationAddressEmail* Phone Number (including country code)* General Questions1. What problem are you trying to solve?* (Please explain how long you have been trying to solve this issue)2. Have you been seeing another medical professional or practitioner related to this problem? (please explain)*3. How do you sleep?*(Describe including hours)4. How would you describe your mental health and or mindset?*(ie are you in a stressed workplace or mindset)5. Do you have a good bowel movement every day? ( not constipated or the lose movements) [Yes or No]*YesNo6. How often do you drink alcohol?*AbstainRarely (1 or 2 glasses a month)Sometimes (1 or 2 glasses a week)Moderate (1 or 2 glasses several nights a week)Often (I need a wine or beer to relax most nights)I have a drinking problem7. Do you eat your food at your desk while doing emails or in busy meetings or in a relaxed state?*At desk while doing emailsIn busy meetingsIn a relaxed stateAllOther (If Other, please specify.)Others (Please specify))*8. Do you exercise? (Yes or No)*YesNo9. Exercise activity per week*1x per week2x per week3x per week4x+ per week10. Type of Exercise*JoggingBoxingHIITOther11. How important is it to you that you find answers to this problem and solve it (1-10, 10 is best important)*PhoneThis field is for validation purposes and should be left unchanged.