Nutrition Intake Form

Today's date *
Today's date
Name *
Name
Gender
Birthday *
Birthday
Stress level *
Are you currently pregnant?
*Required for women only to answer
Do you smoke? *
Liability agreement *
By checking the "I agree" box below, I acknowledge that I understand that Astrid Bengtson is a health consultant and not a physician, and that I should see a doctor if I think I have a medical condition. I understand that Astrid Bengtson will not be held liable for failure to diagnose or treat an illness, nor will she be liable for failure to prevent future illness. Additionally, I promise to give Astrid Bengtson a complete and accurate account of any medical conditions that I may have and any medications that I am taking.