Home
Belvaspata
Benefits of Belvaspata
Distance Healing
Nutritional Counseling
Program Benefits
Health History Form
Recommended Products
About Alana
Testimonials
Guest Book
Newsletter & Events
Contact Us

Health History

If you have already scheduled a health consultation with Alana, please complete the confidential Health History Form below. This should be completed and submitted prior to your appointment. 

Thank you.

* Required fields
Name *
E-mail Address *
Address *
Phone - Work
Phone - Home *
Age *
Height *
Date of Birth
Current Weight *
Weight 6 months ago *
Weight 1 year ago *
Would you like your weight to be different *
If so, what?
Relationship Status *
Do you have children?
Occupation *
How many hours a week do you work? *
Do you sleep well? *
Do you wake up at night? *
If yes, approximately how many times?
To urinate?
What time do you get up in the morning? *
Do you experience constipation or diarrhea? *
If yes, please explain
What blood type are you? *
What is your ancestry? *
Women: Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic?
Please explain
Do you take any supplements or medications? If so, which? *
Are there any healers, helpers or therapies with which you are involved? Please list: *
What role does exercise play in your life? *
Do you drink coffee, smoke cigarettes or have any major addictions? *
What percentage of your food is home cooked? *
Where do you get the rest from? *
List any serious illness/hospitalizations/injury *
How is the health of your mother? *
How is the health of your father? *
What is your chief concern? *
List any other concerns *
What is your diet like?
What is your diet like? BREAKFAST *
LUNCH *
DINNER *
SNACKS *
LIQUIDS *

I have read and agree to the Privacy Policy *

Spam prevention


Please enter the code shown above and click the 'Submit Form' button. This additional step is required to help protect against message spam.

Enter code above: