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Client Consult Form

It’s helpful if I know your health history and current status before we speak. This information will remain confidential and can be deleted from my database at your request.

Disclaimer: Mousa Khalife and Keto Therapy LTD do not provide medical advice, diagnosis or treatment. Nutritional consultation is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare providers regarding a medical condition. Never disregard professional medical advice or delay in seeking it.

Name *

First

Last

Sex

Age

Height & Weight

Nationality

Email *

Phone Number / Whatsapp

City

Check all the health problems that apply

Diabetes
High Cholesterol
High blood pressure
Allergies
Asthma
Sinus issues
Anxiety
Headaches
Skin issues
Frequent urination
Fluid retention
Cold feet & hands
Hair loss
Low sex drive
Acne
Puffy under eyes
Red cheeks
Loss of eyebrows
Varicose veins or spider veins
Difficulty seeing in the dark
Out of breath when climbing up stairs
Repetitive infections such as (sore throats, lung, sinus)

Kindly list all health conditions or concerns not mentioned above in the checklist & you want help and improvement with.

Do you have cancer? If yes, when did you first get diagnosed? What is its type & stage?

Are you currently on any medications? If yes, list them.

List any vitamins, supplements or/and herbal remedies you are currently using.

Do you have any non-food allergies or sensitivities? If yes, list them below.

Do you have any Autoimmune Disease? Describe.

List any previous surgeries you had (Gallbladder removal, appendectomy, thyroid, tonsils, etc..)

What’s your digestion like? Do you suffer from bloating, constipation, indigestion, IBS, or/and acid reflux?

Where do you have pain, inflammation or stiffness?

Describe your sleep, both in quantity and quality.

Describe your energy level (include how you feel when you wake up and throughout the day).

How would you describe your current cognitive state (concentration, tolerance to stress, memory, focus)?

What kind of health problems run in the family?

How frequent is your bowel movements (per day or per week)?

Did you go through any significant stress events (losses of loved ones, divorce, etc.)?

Do you experience emotional eating, stress eating, or snacking out of boredom?

Do you drink alcohol? If yes, describe the type, amount, and frequency of your past and present use of alcohol.

Describe your current type of exercise program if any.

Please indicate any abnormal blood test, hormone test, urine test, MRI, etc.

What are your goals in adopting this diet?

Briefly describe your current eating regimen.

Have you ever followed a low-carb plan before? (e.g. Atkins, Carnivore)

Is there anything else you want to communicate about?

mousa@myketotherapy.com

Lebanon, Tyre, Keto Therapy Clinic,

Samhat Center #306,

+961 76 944 911
.

Zambia, Lusaka, Keto Therapy Clinic,

Mpulungu Rd Plot 19303,

+260 97 3001700