Kitchari Cleanse &/or NHM Health Goals

First Name: *
Last Name: *
Daytime Phone: *
Email: *
Gender:
Age: *
Date of Birth:
Patient Address
City:
Zip Code:	(5 digits)
State:
Height:
Current Weight:
Desired Weight:
Blood Pressure:
Temperature:
Color of Tongue:	Pink Pale Red Purple Swelling Dry
Radial Pulse Check:	beats per minute?
When touch with three fingers is it full:	Thick Thin Thready
What is color of the coating on your tongue:	White Yellow None
Western medical diagnosed ailments:
Western medicines prescribed for above ailments and currently taking:
Current nutrition program:
Current Sleep patterns:
Current Exercise routine:
Family history - genetic factors:
Physical limitations affecting exercise/movement:
Have you ever tried a Kitchari Cleanse?	Tried Not Ever Tried
If You ever tried A Kitchari cleanse if so from where and what was the outcome?:
Any other comments or concerns: