Revisit Form - Denny Waxman Macrobiotic Counselor

Date

MM slash DD slash YYYY

Name

Address

Street Address Address Line 2 City State ZIP Code

Work Phone

Home Phone

Cell Phone

Email

Accompanied by?

Relationship to you?

Weeks, months or years of macrobiotic practice?

Have your read The Ultimate Guide to Longevity?

What was your original problem?

Are you under medical care or supervision?

Are you taking any medications or treatments at the present time?

Do you feel better since your last visit?

If yes, in what ways?

What physical or mental improvements have you experienced?

What would you like to improve most?

Are you experiencing any problems or symptoms now?

What physical or mental improvements have you experienced?

How well have you followed the recommendations?

Which of the recommendations are you having the most difficulty with?

Do you enjoy the food and cooking?

Do you cook with?

What is your approximate body weight?

Height

How is your appetite?

How is your bowel movement?

How many times a day do you urinate?

Color of urine?

How much and what type of exercise do you get?

Any Comments?

Are you comfortable with having a Scribe to take notes?*

Are you comfortable with a student-counselor being present during this consultation (Zoom-ONLY)?*

Digital Signature:*

By electronically signing above, I certify that I have read and agree to the Counseling Disclaimer.