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Julian Christopher Cortez, M.Ed., M.A.

Holistic Health
Practitioner






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Revisit Form
          

Full Name    

Email Address    Phone

What positive changes have you noticed since your last appointment?


What are your main concerns at this time?


Have you:
Lost Weight? Gained Weight? How many lbs?  

How is your sleep pattern?

Do you experience constipation or diarrhea?

How are your sugar cravings?

How are your energy levels?

How is your mood?


Are you cooking more?  What foods do you crave?


How is your diet these days?
breakfast
   lunch
   dinner
   snacks
   liquids

Any other comments?


Which of the following do you use, and how often (if applicable)?
Tongue Scraper? Hot Towel Scrub? Hot Water Bottle?

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Julian Christopher Cortez, M.Ed., M.A. | 6440 Palmetto Street - Ridgewood, NY 11385