The Acustaple Way

Register for a Meeting

All questions contained in this form all strictly confidential. Personal Information

Location:

Date:

Last Name:

First Name:

Middle Initial:

Address:

City:

State:

Zip Code:

Email:

Date of Birth:

Age:

Gender:

Male

Female

HomePhone:

CellPhone:

Work Phone:

Ext.

Reason for havling the Ear Stapling procedure and what are your desired results (ie. Stress/Tension, Weight Loss, Quit Smoking, etc...):

DIET & NUTRITION BACKGROUND INFO

Exercise:

Sedentary (No exercise
Mild (i.e. climb stairs, walk 3 blocks, golf)
vigorous exercise (i.e. work or recreation, less than 4x/week for 30 minutes)
Regular vigorous exercise (i.e. work or recreation, 4x/week for 30 minutes)

Diet:

Are you Dieting?   Yes   No
If Yes, are you on a physician prescribed medical diet?   Yes   No
Number of meals you eat in an average day?
Rank Salt Intake: High Medium Low
Rank fat Intake:   High Medium Low

Caffeine:

None Coffee Tea Cola
# of cups/cans per day?

Please list any medical conditions you feel we should be aware of. Especially anything that affects your Immune system.

GENERAL QUESTIONS

How much water do I drink each day?

How much activity do I have each day? Type?

Hormonal Influences?

Is there unusual stress in my life?

What is my emotional state?

How many diets have I been on in the past?

Name of Diets: