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Inquiry Form
The Broma Lisestyle Center
Your Wellness, Our Mission
Name
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Email Address
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Phone
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Street Address
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Virgin Islands, U.S.
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Emergency Contact
*
Hight
*
Weight
*
BMI
*
Body fat %
*
Breathing
*
Blood Pressure
*
Blood glucose
*
What is your occupation or daily activity?
List your main reasons and concerns for your visit.
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What are your 5 major health and nutrition concerns or problems?
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What Time Do You Normally Eat?
*
Hours
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12
01
02
03
04
05
06
07
08
09
10
11
Minutes
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02
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AM/PM
AM
PM
List what foods do you normally eat
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What did you eat for breakfast yesterday?
What did you eat for lunch yesterday?
What did you eat for dinner yesterday?
List any heart and circulation:
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List breathing and lungs problems
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List skin and hair problems
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List urinary and Kidney problems
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List bone and joint problems
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List any other lifestyle and health problems.
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How much time do you spend outdoor in the sun?
Do you carry a water bottle with you daily?
How much water do you drink per day?
Do you do a lot of physical activities or on an exercise program?
How many hours of activities per day?
List all your current medication, their amount and time you take them.
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List all food supplements, their amount and the time you take them.
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Do you drink alcohol? If so how much?
Do you smoke? If so, what do you smoke and how much?
Do you use any kind of drug or stimulant? If so what kind and how often?
What is your normal bed time?
What is your normal wake time?
Are you a spiritual person? Or do you believe in a Creator?
How important is this belief to you?
What would you like us to help you with?
Submit
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