Wellness Weight Test

Home
About
Go To Store
Services
Appointments
- Book Phone Appointment
- Book New Client Appt.
EMF Cell Neutralizers
- EMF Demo
Free Tests
Articles
Blog
- Newsletters
- Testimonials

Home
About
Go To Store
Services
Appointments
- Book Phone Appointment
- Book New Client Appt.
EMF Cell Neutralizers
- EMF Demo
Free Tests
Articles
Blog
- Newsletters
- Testimonials

Dr. Valerie Nelson

Board Certified Natural Integrative Doctor

As soon as you have submitted this form, be sure to send us an email at [email protected] (Please be sure to answer every question, or we will not receive it.) We are excited for you to begin this wellness journey for a slimmer and more energetic you!

Name

Email Address

Phone

Address

City, State, Zip

Birthday Including Year

What is your current weight?

What is your goal weight?

What are your favorite foods and cravings?

How many hours of sleep do you get a night?

Do you sleep soundly?

How often do you move your bowels?

On a scale from 1 - 10, how do you rate yourself as far as being a healthy eater? (1 being low)

On a scale from 1 - 10, what is your energy level?

On a scale from 1 -10, what is your stress level?

On a scale from 1 - 10, what is your pain level?

Please describe your pain, if applicable.

Current Medications

Please check off the following health symptoms for Dr. Nelson's review. This will help her to customize your wellness program.

Acid Reflux (GERD)Alcoholic TendenciesAll Over Body OdorAllergiesAnemiaAnxietyArthritisAsthmaAutismBackacheBad BreathBed WettingBell's PalsyBipolar DisorderBlood Sugar IssuesBloody StoolsBone WeaknessBronchitisBurning Sensation - StomachCancerCeliac DiseaseChronic ConstipationChronic FatigueChronic InfectionsConstant HungerConstant ThirstCrawling Sensation Under Skin - NightChron's DiseaseCysts and FibroidsDark Circles Under EyesDepressionDiabetesDiarrheaDigestive ProblemsDisturbed Sleep - Multiple AwakeningsDizzinessDrooling While SleepingDry SkinEczemaEmphysemaEndometriosisEpilepsyExcessive All Over WeaknessExcessive Body OdorExcessive SalivaFungus - ToenailsHair LossHeadachesHeart PainHeart ProblemsHeavy Menstrual BleedingHot FlashesExplosive Bowels Soon After EatingEye Problems - e.g., TwitchingFertility ProblemsFibrocystic BreastsFibromyalgiaFood AllergiesForgetfulnessFrequent UrinationGallstonesGas and BloatingGoutHemmorrhoidsHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHigh TriglyceridesHivesInability To Gain WeightInability To Lose WeightIndigestionInsomniaIrregular HeartbeatIrregular Menstrual CyclesIrritable Bowel SyndromeItchy AnusItchy EarsItchy NoseItchy SkinJoint PainsKidney ProblemsKidney StonesLeaky Gut SyndromeLethargyLiver CirrhosisLong Standing ObesityLoss of AppetiteLow EnergyLupusMalabsorption SyndromeManic DepressiveMemory ProblemsMeniere's DiseaseMenopauseMenstrual DisordersMigrainesMood SwingsMucous in StoolsMuscle PainNarcolepsyNauseaNerve TwitchingNervousnessNicotene AddictionNumbness or Tingling in Hands and FeetPain in Shoulders That Radiates Down ArmPain in the NavelPain in the ShouldersPains in Various Parts of the BodyPancreatitisParkinson's DiseasePolycystic Ovarian SyndromePoor CircuationPoor Immune SystemPremenstrual SyndromeProstate Problems - EnlargedRapid HeartbeatRashesRespiratory ProblemsRestless Leg SyndromeRestlessnessRosaceaSchizophreniaSinusitisSkin ProblemsSlow RefluxesSudden Weight GainSudden Weight LossTeeth Grinding at NightThyroid ProblemsTinnitusUlcerative ColitisUnclear ThinkingUrinary Tract ProblemsUterine FibroidsVaginal DrynessVaricose VeinsVertigoWartsWater RetentionYeast Infections

Would you like Dr. Nelson to recommend supplements to you based on your health test? *

YesNoI'm already on her supplements

Please e-mail Jenna at [email protected] whenever you complete this form. If you do not answer all the required questions (*), the form submission will not work.

Okay

Would you like Jenna to pray with you?

YesNo

This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.

Please email Jenna at [email protected] to let her know that you completed your form. Please email Jenna at [email protected] to let her know that the form was submitted.

Holistic Doctor

Homeopathic Doctor

Abundant Life Wellness

Dr. Valerie Nelson, Board Certified Natural Integrative Doctor

© 2014 Abundant Life Wellness.

All Rights Reserved.

/

Lightbox image