Amazing Kitchari 
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Kitchari Cleanse &/or NHM Health Goals

First Name: *
Last Name: *
Daytime Phone: *
Email: *
Age: *
Date of Birth:
Patient Address
Zip Code: (5 digits)
Current Weight:
Desired Weight:
Blood Pressure:
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: