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Kitchari Cleanse &/or NHM Health Goals
First Name:
*
Last Name:
*
Daytime Phone:
*
Email:
*
Gender:
Female
Male
Other
Age:
*
Date of Birth:
Patient Address
City:
Zip Code:
(5 digits)
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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: