Let’s work together Name * First Name Last Name Email * Phone * Country (###) ### #### Date of Birth * MM DD YYYY Time of Birth (if known) Hour Minute Second AM PM Please detail your health history, including everything you've done & tried up until now * List any medications and previous/ongoing health issues * List any and all health symptoms & issues you want to address while working together * Describe what results you would like to achieve from us working together * With that in mind, What would success look like to you at the end of our time together * List any nurtitional requirements or allergies you have * Any additional information you'd like to include Thank you!
