Application for Detox for Weight Loss NAME_________________________________________________________ ADDRESS______________________________________________________ CITY, STATE, ZIP _______________________________________________ HOME PHONE __________________________ CELL PHONE ___________________________ EMAIL ______________________________________________ HEIGHT ___________________ WEIGHT _____________________________ Present Health Issues: _______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ What Pharmaceutical Drugs are you currently taking? _____________________________________________________________ Reason: 2)______________________________________________________________ Reason: 3) _____________________________________________________________ Reason: _____________________________________________________________ Reason: Do you smoke? Yes___________ No _________________ Do you have High Blood Pressure? Yes___________ No _________________ Do you have High Cholesterol? Yes___________ No _________________ Do you have Diabetes? Yes___________ No _________________ What are your favorite foods? What are your least favorite foods? What are your favorite flavors? What are your least favorite flavors? Do you like Sweets? Yes___________ No _________________ Do you like Salty? Yes___________ No _________________ Do you like Bitter? Yes___________ No _________________ Do you like Crunchy? Yes___________ No _________________ Do you like Sour? Yes___________ No _________________ Food Diary: Prepare for me a three day food diary. List all of the foods and beverages you eat. List the time you ate them. Bowel Movement Diary: Prepare for me a three day bowel movement diary. I want to know the time you move the bowels throughout the day. How many times you moved the bowels per day. Describe the stool for me: a) Was it soft, firm or hard? b) Was it in one long piece or small pieces? c) Did the stool float or sink? d) What color was the stool? Email this application to: Rose@imherbalist.com OR Mail this application to: DETOX FOR WEIGHTLOSS Rose Kalajian - Herbalist 26403 Chianina Drive Zephyrhills, FL 33544