Below you will find a PDF file which you can download, fill in, scan and return to me via email or fax 815-550-2953.

During your initial visit, we will discuss your present health goals and your health history. This conversation is based on the intake form above.  The information you share with me will facilitate the appropriate choice of dietary and herbal recommendations to fit your unique needs. These recommendations will be guided by your goals, constitution, history (personal and family), symptom patterns, nutrient and caloric needs, and food preferences and/or sensitivities (if any).

Intake Form

For your fist consultation, I would also like you to bring with you any nutritional supplements, herbs and/or pharmaceutical drugs you are taking; as well as any recent lab tests or blood tests or other pertinent medical information you think may be helpful.

Your information will be kept confidential. Please read my privacy statement below. I will ask you to sign this before we begin our work together.

Privacy & Informed Consent Statement

I look forward to partnering with you towards optimal health!

Revisit form: For a followup consultation, please fill in the following intake form that will give me a snap shot of your current health and dining habits.