Yachter Bio-Nutritional Department: Progress Report

Wellness Progress Report

GENERAL INFORMATION

Name Todays Date

Age Date of Birth Female Male Height Weight

Have you been faithful in taking your recommended supplements? Yes No

If no, explain.

Have you followed the Food Plan recommendations? Yes No

If no, explain.

Have your symptoms gotten better? Yes No

If Yes, explain.

Have your symptoms gotten worse? Yes No
If Yes, explain.

Have you started taking any new medication since you last gave us your medication list? Yes No
If Yes, explain.

Have you started taking any new supplements (besides the recommended supplement list we gave you) since you

last gave us your supplement list? Yes No

If Yes, explain.

Have you received any vaccinations since you last gave us your immunization history? Yes No

If Yes, explain.

Additional information for us to know:

For women: Are you pregnant? Yes No Are you breastfeeding? Yes No

Are you cyclic? Yes No Date of last cycle: Are you in Menopause? Yes No

CURRENT COMPLAINTS/CONCERNS

Please list your current symptoms in order of decreasing severity, starting with the worst one. Please list the frequency of this problem, and then check the severity of the symptom.

Problem	Frequency	Mild	Moderate	Severe
1
2
3
4
5
6
7