Revisit Form


Name

Email Address    Phone

What positive changes have you noticed since your last appointment?


What are your main concerns at this time?


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?