THIS IS YOUR PERSONAL LIFESTYLE BOOKLET THAT GOES

ALONG WITH YOUR PROFILE EVALUATION RECOMMENDATIONS

KEEP……………..THIS BOOKLET!

REVIEW.………IT EVERY WEEK!

ATTENTION!!!

BRING………IT WITH YOU FOR

EACH…INDIVIDUAL APPOINTMENT!

To help you remember your scheduled evaluations, please record your re-

evaluation dates and time here: You may tape your sessions.

(Be considerate – if you have a personal appointment, please give

coordinator at least 24 hours notice if you need to cancel!)

DATE TIME DATE TIME

Name (Please print)

Occupation

Marital Status: MARRIED DIVORCED SINGLE WIDOWED SEPARATED (Circle)

Others

Weight Age Height

Appendicitis Tonsillitis

Others No

Medications:

Estrogen Birth Control Pills

Do you smoke? # of years you have smoked in the past

# of meals per day Average # of bowel movements per day

Donald Gene: Kraus - Body Life Direct

Street City___________________ ST._________ Zip________ _________________

_State _____ Zip ______________________

Phone ( ) -

Biochemist/Lifestyle Consultant

Client Evaluation Booklet by

Surgeries: Gall Bladder Hysterectomy-complete or partial

NEXT APPOINTMENT DATE:

www.bodylifedirect.com-WEB Site

E-mail-bodylife@mail.com—ph. # 423–552–3631

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