GENERAL INFORMATION SHEET
This questionnaire is for educational purposes only and is not intended to treat individuals. If clients’ have a medical
diagnosis, they are encouraged to seek out treatment from a qualified medical doctor. Check any boxes if the
question applies to you. Please fill out and return to Josephine at her fax 604-685.6518 or by email at
[email protected]. For more information visit: www.naturalhealthprotocol.com
Name_______________________________________ Age____ Sex: F M
Date_________________________
Address_____________________________________________________________
City____________________________ State/Prov.___________________________
Zip/Postal Code_______________________________________________________
Home Phone_________________________Other Phone______________________
E-Mail Address_______________________________________________________
Height________ Weight_________
Occupation________________________ Ethnicity___________________________
How were you referred? ________________________________________________
What are your main health concerns or conditions?
______________________________________________________________________
______________________________________________________________________
Please list any medications or food supplements you are currently taking:
______________________________________________________________________
______________________________________________________________________
Please list any recent medical tests results you have, such as blood tests:
______________________________________________________________________
______________________________________________________________________
Please list illnesses in your family such as heart disease, cancer, TB, diabetes or
arthritis.______________________________________________________________
______________________________________________________________________
DIET: What are examples of typical breakfasts for you? Beverages
_________________________________________________|____________________
_________________________________________________|____________________
Mid-morning
Snacks___________________________________________|____________________
What are typical lunches for you?
_________________________________________________|____________________
_________________________________________________|____________________
Mid-afternoon
Snacks___________________________________________|____________________
What are typical dinners for you?
_________________________________________________|___________________
_____________________________________________________________________
Evening Snacks____________________________________|____________________
How often and what kind of exercise do you do?
______________________________________________________________________
______________________________________________________________________
About how many hours of sleep do you get per day?
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I understand that nutritional balancing is a means to reduce stress and balance body chemistry. It is not intended as
diagnosis, treatment or prescription for any condition or disease. I understand that Josephine Zanetti works as an
unlicensed nutrition consultant.
Signed____________________________________ Date____________
Name______________________________________________________
SYMPTOMS SHEET
CIRCLE any conditions or symptoms that presently describe you.
PLACE A STAR next to the symptoms most important to you.
Joint Pain Eczema Sinus Headaches
Joint Stiffness Fungal Infections/Candida Tension Headaches
Arthritis, Osteo Psoriasis Migraine Headaches
Arthritis, Rheumatoid Hives Neuritis
Muscle Pain Hair Loss Eye diseases
Muscle Weakness Slow Wound Healing Constipation
Muscle Cramps Cataracts Diarrhea
Bursitis Glaucoma Intestinal Gas
Fractures Meniere's Disease Bloating
Osteoporosis Tooth Decay Heartburn
Gout Excessive Plaque on Teeth Ulcer
Gum Disease Stomach Pain
Sweet Cravings Colitis
Sugar Reactions Infections/Viruses Gall Stones
Irritable before meals Tumors/Cancer Fissures
Can't Skip Meals Multiple Sclerosis Hemorrhoids
Hypoglycemia Parkinson's Disease Cirrhosis
Crave Starches Scleroderma Diverticulitis
Fat Cravings Fear Tend to Gain Weight
Other Food Cravings Anger Tend to Lose Weight
Food Allergies Anxiety
Excessive hunger Bipolar Disorder Anemia
No hunger Brain Fog Easy Bruising
Diabetes Confusion
Depression Dental Amalgams
Rapid Heart Rate Irritability Drug Addiction
Skipped Heart Beats Mind Races Alcoholism
Heart Palpitations Mood Swings Smoking
Heart Attack Obsessive/Compulsive
Poor Circulation Panic Attacks WOMEN:
Dizziness Poor Memory Premenstrual Syndrome
Low or High Blood Pressure Schizophrenia Water Retention
Angina Trouble Sleeping Cramps
Arteriosclerosis Suicidal thoughts No Menstruation
High Cholesterol______ Autism Heavy periods
High Triglycerides____ Attention Deficit Light/Irregular Periods
Hyperkinesis Ovarian Cysts
Cough Dyslexia Fibroid Tumors
Bronchitis Seizures Abnormal Pap Smear
Asthma Learning Disability Menopause
Post-nasal Drip Mental Retardation Fibrocystic Breasts
Sinus Congestion Delayed Development Breast Tumors
Allergies Yeast Infections
Emphysema Bladder Infections Hot Flashes
Kidney Infections Currently pregnant
Fatigue Trouble Urinating Abuse
Hypothyroidism Frequent Urination Rape
Low Body Temperature Painful Urination
Cold in Winter/Dry Skin Kidney Stones MEN:
Tend to Gain Weight Water Retention Prostate Problems
Hyperthyroidism Kidney Stones Impotence
Acne Water Retention Infertility
Other Symptoms or Comments: ________________________________________________________
___________________________________________________________________________________
Congratulations you are taking a great step towards better health and wellness!
Doctor Notification Policy:
It is common practice for naturopaths, nutritionists, and other non-licensed practitioners to
collect your signature on a liability waiver form such as this. By doing so you
acknowledge that you are responsible for your health and wellness.
The undersigned agrees that Josephine Zanetti FDN of Natural Health Protocol.com perform a
Hair Analysis Interpretation and set up a Nutritional Balancing Program for the undersigned for
the purpose of reducing stress and enhancing my health. You understand that Nutritional
Balancing is a means to reduce stress and balance body chemistry. Josephine does not
diagnose, cure or treat any illness or disease, physical or mental. It is also not intended to,
cannot and should not be expected to substitute for a personal consultation with regular medical
care from a physician.
The undersigned understand that Josephine Zanetti is not licensed, works as a Nutritional
Balancing and Lifestyle Coach, has obtained a Nutritional Certificate from the Canadian School
of Natural Nutrition and FDN, and is a practitioner of HTMA Nutritional Balancing Science
trained with Dr. Lawrence Wilson and his health associates.
The undersigned releases Josephine Zanetti from any liability for injury or loss arising out of the
use of, or reliance on, the laboratory results and/or the dietary, supplement and lifestyle
suggestions provided. Before making any changes to the exercise, diet or nutritional
supplementation of the undersigned, a physician should be consulted.
The undersigned understand it will take 3 to 4 weeks to receive his or her program by mail
(International Clients may take longer) after we receive your hair sample and there are no
refunds.
_________________________________________ ___________________
Signature Date
Schedule of Fees:
Initial Hair Mineral Analysis Test is: $430.00 (family of three) which includes lab test,
phone consultation(s), interpretation of Hair Analysis Report and continued wellness
coaching for 3 consecutive months and more.
Repeat Hair Mineral Analysis Test: $190
I have read and understand the fees listed above and understand that payment is due at time of
service. I also understand that all fees are subject to change without notice. I also understand that
upon payment, there is no refund after 30-days.
Signature:________________________________________
Date:____________________________________________
