ENCUESTA DE SALUD

Nombre: _____________________________________________ Fecha: ____________________________Dirrecon: _________________________________________________________________________________Telephono: ____________________ Fec ha de Nac: ____________________________________________Sexo: ________________ Edad:_____________ Estatura: ___________________

__________________________________________________________________________________________Preblemas de Salud:

__Diabetes __ Presión Alta __Acides __Colesterol __Cancer__Estreñimiento __Gastritis__Asma__Ansidad

__ Dolor de Extremidades __ Varicies __ Fatiga__ Problemas Mentruales __ Insomnio __ Depression __HIV __ Nervioso __Dolor de Cabeza __ Colitis

__ Diverticulitis __ Alergias __Estres __ Falta de Energia __Problema de los Riñones __Problemas del Higado __Acné__ Caida De Cabello __ Psorisis

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Productos: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Refeidos: Tele/email

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HOJA DE PESO

Fecha Peso Peso Accumulada

Peso Bajado Grasa Visceral BMI Musculo

HEALTH SURVEY

Name ___________________________________________________Date: ____________________________Address: _________________________________________________________________________________Telephone: _____________________________ DOB : ____________________________________________Gender: ________________ Age: _____________ Height: ___________________

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Health Problemas:

__Diabetes__ High pressure__Acides Reflux__Cholesterol__Cancer__Constipation__Gastritis__Asthma__Aniexty

__ Varical Viens __ Fatigue__Menstrual problems__ Insomnia__ Depression__HIV__Nervous _Headache__ Colitis

__ Diverticulitis__ Allergies__Stress__ Lack of energy __Problema Kidney___Liver __Problemas__Acne

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Products: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________

Referals: Tele / email

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