Blood Type Diet Form CONFIDENTIAL CLIENT INFORMATION FOR: Live Right 4 Your Type: Blood Type DietNAMEMALE/FEMALEMALEFEMALEDATETimeHours-120102030405060708091011Minutes-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AM/PMAMPMADDRESSCITYSTATEZIPBIRTHDATEHOME PHONEWORK PHONEEMAILWEIGHTHEIGHTWHO REFERRED YOU?OCCUPATIONPlease list your daily meal plan: (i.e. What do you eat on a daily basis?)PLEASE CIRCLE ANY OF THE FOLLOWING CONDITIONS YOU ARE EXPERIENCING:EMOTIONAL CHANGESHEADACHESSKIN DISORDERSHYPOGLYCEMIAPHLEBITISPMS SYNDROMEHEART AILMENTDIABETESPREGNANCYSLEEPLESSNESSFLU/COLD/FEVERINFECTIOUS DISEASEWEIGHT GAINCANCERVARICOSE VEINSALLERGIESCHRONIC/ACUTE PAINFIBROMYALGIAOSTEOPOROSISHIGH BLOOD PRESSUREDIGESTIVE PROBLEMSARTHRITISULCERATED COLONKIDNEY AILMENTARE YOU CURRENTLY UNDER THE CARE OF A HEALTH PROFESSIONAL?PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING:DO YOU KNOW YOUR BLOOD TYPE?YESNOIF YES, PLEASE LIST:SECRETOR / NON-SECRETOR / UNKNOWNSECRETORNON-SECRETORUNKNOWNIS EXERCISE A PART OF YOUR DAILY REGIMEN?YESNOIF YES, WHAT TYPE?I understand that each blood-type prescription shows how, according to my blood-type, I should adapt my lifestyle, deal with stress, and put into practice the right strategies for aging, to achieve emotional balance, maximize my health, and overcome disease. I further understand that my participation in the Blood Type Diet Program should not be construed as a substitute for a medical examination, diagnosis or treatment, and I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment I am aware of. I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile, and I understand there shall be no liability on the practitioners’ part should I forget to do so.Client AcceptanceCLIENT FULL NAMESubmit