Initial health consultation with Intelligent Eating

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Intelligent Eating
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Use this page to request a complimentary discovery session to discuss improving your health, with Adam Stevens.

This initial consultation will help you:

Understand the reasons why you have confusion on what to eat
Enable you to find out why diets do not work
Have clarity on how to achieve your health goals quickly

It is a 45 minute consultation, over the telephone or Skype.

How to apply

Please complete, and submit the form below as honestly as possible.
Please schedule a time that suits you for a conversation.

Please note, Intelligent Eating is not for everyone, and if it’s deemed that Intelligent Eating isn’t for you, there may well be resources we can refer you to.

This form is confidential in accordance with 4, 4.1, 4.2, 4.3, 4.4, and 4.5 of our terms and conditions, which are available in full on request.

Discovery form

First Name *

Last Name *

Your address *

Your date of birth *

Email Address *

Telephone (home)

Telephone (mobile) *

Skype name & time zone *

List all prescription medications, over-the-counter drugs, or vitamin/mineral supplements you are taking *

If none, please write 'none'

List all allergies to medicines, and the reaction you had *

If none, please write 'none'

List any food allergies *

If none, please write 'none'

Do you have, or have had, any symptoms in the following areas to a significant degree?

Skin

Head/Neck

Ears

Nose

Throat

Lungs

Chest/Heart

Back

Intestinal

Bladder

Bowel

Circulation

None

Other

Please tick any boxes where recent changes have occurred.

Weight

Energy Levels

Ability to sleep

Pain/Discomfort

Other

None

Have you been medically diagnosed with any of the following?

Type 1 diabetes

Acne

Type 2 diabetes

Rheumatoid arthritis

Osteoarthritis

Angina

Coronary artery disease

Peripheral artery disease

Varicose veins

Gout

Gastroesophageal reflux disease

Alzheimer's disease

Asthma

Cancer

Hyperlipidemia (high cholesterol)

Crohn's disease

Depression

Anxiety

Endometriosis

Fibromyalgia

Hypertension

Multiple sclerosis

Parkinson's disease

Heart (cardiac) arrhythmia

None

Other

What is your current weight (in any units, but please state which)

What is your height (in any units, but please state which)

What is your resting pulse? (please ask if you require help to measure this)

What is your most recent HbA1c? e.g. 40 mmol/mol

What is your total cholesterol in mmol/l? e.g. 4.6 mmol/l (if known)

If you know your LDL, HDL cholesterol and blood triglycerides, please write them below. e.g. LDL 1.7 mmol/l, HDL 1.1 mmol/l, Triglycerides 1.8 mmol/l

With respect to exercise tolerance and ability, how would you describe yourself currently?

Very little tolerance

Able to tolerate short bursts of exercise

Able to tolerate significant exercise

Able to run half a mile

Able to run a mile

Able to run a marathon

Please write your health goals below. Be as specific as possible, and please feel free to be open - this will be discussed sensibly and with respect.

What do you find your biggest challenges to achieving your health goals to be?

On a scale of 1-10 (where 10 is the highest), how serious are you about transforming your health through solving these challenges? *

1

2

3

4

5

6

7

8

9

10

What's your number one health goal right now? *

What are you doing at the moment to achieve your health goal? *

Why do you think Adam could be the right person to help you? *

Anything else you'd like to add.

If you have not already done so, please book a time for our initial discovery consultation using the online calendar below.

Intelligent Eating®

© Intelligent Eating 2014

Terms & Conditions

Registered company number in England and Wales: 08199066

The information and recommendations given within this website are not intended to be a substitute for medical advice. If you have a medical condition or any symptoms giving rise to concern you are advised to consult your medical practitioner. If you have already, and aren’t happy then get in touch, we may be able to offer advice.

Case studies, and praise represented on this website are from people who have agreed to our terms and conditions as well as working closely with their doctor, where appropriate. Do not attempt to emulate their results without first contacting us.

No responsibility can be taken for the information contained by following any external links from this site, and please respect that the content contained within this website is subject to copyright.

All correspondence is strictly confidential as per our terms and conditions.

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