Rosanna’s Macrobiotic Consultation Form

Please fill this form out completely. All fields with an asterisk (*) are required.

*Your Name

*Mailing Address:

*Day Phone
*Night Phone

*E-mail Address

*Date of Birth (MM/DD/YY)


*Marital Status
*Number Of Children

General Complaints:
 Allergies: food, dust, pollen, mold, animal Weak immunity: frequent colds, infections, etc. Asthma Skin: dry, loose, rashes, pimples, psoriasis, other Fatigue or anemia

Common Aches and Pains:
 Headaches Muscle cramps Repetitive strain injuries (carpal tunnel syndrome) Backaches Arthritis Rheumatism

 Diarrhea or constipation Poor digestion Hemorrhoids Ulcers: stomach or duodenal Colitis (irritable bowels)

 Poor circulation (cold hands and feet) High or low blood pressure High cholesterol

 Overweight Underweight Ideal weight

Reproductive and Urinary (Male):
 Frequent urination, day or night Inflamed prostate Lack of vitality or libido Low sperm count

Reproductive and Urinary (Female):
 Urinary and bladder infections Pre-menstrual symptoms Vaginal discharge or dryness Irregular or no menstruation Menopausal symptoms

Stress and Blood Sugar:
 Stress Hypoglycemia (low blood sugar) Anxiety or panic attacks Sleep problems Lack of concentration and poor memory Excessive sweet cravings Mood swings Depression Irritability

Other Present Concerns:

Past Health problems:

List any medical or alternative treatments that you are currently receiving:

*How often do you cook?
 Often Occasionally Infrequently Never

Which do you use to cook?
 Gas Electric Microwave

*How often do you exercise?
 Often Occasionally Infrequently Never

List types and frequency of all your exercising:

Select all the foods you have been eating frequently (a few times a week):
 Whole or cracked cereal grains Whole grain products (breads, pastas, etc.) Vegetable soups Fresh vegetables, cooked Fresh vegetables, raw Beans Sea vegetables Fish Nuts Seeds Fruit Fruit juices, unsweetened Vegetable oil Herbal teas Meat Poultry Eggs Cheese Other dairy foods Refined flour products Canned foods Frozen foods Sugar or honey Chocolate or carob Artificial sweeteners Soft drinks Spices

Please list your favorite foods:

Please provide any other comments or concerns about your current health condition and eating habits:

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