Your HealthEvaluation Please fill in Your Health Evaluation Today's date* DD slash MM slash YYYY Your First Name* Your Last Name* Date of Birth* MM slash DD slash YYYY Your address Your preferred contact numberSecond contact name Second contact numberPlease fill the box for any health conditions that applies to you: Allergies Amyotrophic lateral sclerosis ASDV (vascular disease) Blood disorders or anaemia Calculi or gallstones Chronic pain or fibromyalgia Cancer, lumps, tumour Chest tightness, shortness or breath asthma Cold sores or herpes labialis Common colds, viral infections, or flu Contusions, bruises, burn or cuts Constipation Colon inflammation or colitis Cystitis or urinary track infection Dementia or Alzheimer’s Diverticulitis Dermatitis, psoriasis, or skin conditions Excess body fat and obesity Excess alcohol and hangovers Exhaustion or chronic fatigue Enteritis or Crohn’s syndrome Hypertension or high blood pressure Hypo- or hyper- thyroidism IBS (irritable bowel syndrome) Insomnia or sleeping disorders Insulin resistance or diabetes Joint problems, arthritis, or osteoporosis Low immunity or recurrent infections Lung infection or bronchitis Menopausal symptoms Migraines or headaches Mood disorder or depression Muscle cramping or aches Otitis or ear infections Parkinson’s. past seizures or neuro-motor disorders Podagra, gout, elevated uric acid Pregnancy or lactating Recent accident or major operation Sinus inflammation (sinusitis) Stomach pain, heart burn or indigestion Stomach ulcers Thrust, fungal infections or candidiasis Varicose veins Other health conditions or symptoms Your responsibilities: 1. To consult with a Medical Doctor or General Practitioner if you have filled one or more of the boxes before commencing a new nutritional program with Shannon Howe from I Cook You Serve. 2. To inform your Medical Doctor or General Practitioner about the Health Evaluation and which health conditions you have checked. 3. To talk with a Medical Doctor or General Practitioner about the kind of nutritional program you wish to commence on and to follow their advice. If my health changes so that you subsequently answer ‘’yes’’ to any of the Client Health Evaluation Ailments undertake to inform Shannon Howe immediately and to talk with a Medical Doctors or General Practitioner about the kind of nutritional program that you am on, and to follow the advice of the Medical Doctor or General Practitioner. Please Confirm:* I have read, understood and agree to the following 3 statements1. I have read, understood, and completed the Your Health Evaluation 2. All questions have been answered to the best of my knowledge 3. I am happy to participate in a nutritional therapy program Please check each of the 3 statements about before completing this form.