Client Questionnaire

Holistic Choices

True Health Mastery - The Science and Ancient Art

First Name and Middle Initial

Last name

Address, City, State, Zip

Area Code, Phone No.

Other Contact Information

Date of Birth

Gender

Height, Weight

Please indicate below how you feel on a day-to-day basis． Describe what problem or affliction you are experiencing.

Medical History: Please indicate what medication/s you are on． Essential: please be sure the spelling of your medications are correct．

Are you going to undergo surgery in the near future? If yes, please explain briefly．

Are you presently recovering from any surgery or illness? If yes, please explain briefly. (This is an important consideration through the healing experience).

Are you currently recovering from an injury? If yes, please describe briefly.

Blood Pressure: Systolic, Diastolic if known.

Do not know.

Blood Cholesterol: HDL, LDL, Overall mg/dl if known.

Do not know.

Liver Enzymes if known.

Do not know.

Serum Protein if known.

Do not know.

Note: It is important for us to know your laboratory values so we can monitor your progress as you build your health． It is recommended that you obtain this information from your physician for your own knowledge and records.

Chronic illnesses, disorders, diseases Currently and Previously

Food or Other Allergies

Digestive Problems?

Goals and Expectations

PRELIMINARY DIETARY ANALYSIS FOR ENERGY EVALUATION

List any supplements you are taking daily, incuding herbs. If possible, list the brands and dosages. Links to products and labels, screenshots are suggested.

What Are Your Health Goals?

Waiver

Holistic Choices works cooperatively as a professional courtesy with the medical community in the spirit of integrative health and cooperation of all health disciplines to provide you with the best possible, informed health options.

Holistic Choices’ professional status is that of teacher of healthful living and not that of medical doctor. It is advocated that you involve your physician while implementing any alternative or wellness program as a precaution and be aware of any contraindications. However, it is your Constitutional right to decline this recommendation．

If you choose to decline to inform your physician, it is essential you provide accurate information about your medications and your current dietary habits to the nutritionist. This prevents possible problems such as adverse drug-nutrient interactions that can affect the drug’s performance or hazardously increase its actions. Some drugs can block nutrient absorption while some nutrients can affect a drug’s desired effect．

I accept the terms and conditions described above

Please notify my physician.

Do not notify my physician.

I have sought the services of Holistic Choices, Mary Esther Gilbert, Holistic Nutritionist． I hereby certify that all of the information I have completed on this form is, to the best of my knowledge, true and correct. Please type today's date and sign your name below in order to proceed with your assessment/analysis/consultation.

Date

Signature

Fees and Qualified Discounts

The normal consultation fee is $197 for 2-3 hours, and includes a complete individual nutritional healing protocol provided to the client in eBook form, which contents will be discussed in detail at the consultation session.

A discounted consultation fee of $129 is available to certain associates (and their referrals) of various companies for which I am a product educator and consultant.

A $65 deposit is required for the analysis/assessment based on the information you provide on the above form, and to compile your nutritional health improvement protocol in eBook form ahead of your consultation session.

This deposit is due upon confirmation of your consultation appointment to allow time in the practitioner's schedule to compile your personal health-improvement protocol. Below are the payment options.

Payment options:

Zelle, Payable to hchoicesthj@gmail.com
VenMo, Payable to @MaryEsther-Gilbert
CashApp, Payable to $MaryEstherGilbert
PayPal + $2 Processing Fee, Payable to hchoicesthj@gmail.com

Consultation By Appointment

Please indicate what day/s and time/s you are available for your consultation, which a specific date and time will then be coordinated.

Please allow 2-3 hours for your comprehensive consultation.

a.m.

p.m.

Thank you for completing this important questionnaire. Mary Esther will be contacting you within 24-48 hours to schedule your consultation appointment.

Thank you for submitting your confidential information. Mary Esther will contact your for your appointment within 24-48 hours.