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Consult Evaluation

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Please copy and complete the following questionnaire, and send it to: askjohnfung&gmail.com

Evaluation Questionnaire

Name:

Email address:

City, State/Country:

Year of birth:

Weight:

Male or Female:

List the health problems that bother you most in descending order:

Do you think you are eating healthy food?

Good appetite? Any food you tend to eat too much?

Do you have a long list of food you are allergic to?

Sleep ok? Easily disturbed in your sleep?

Are you active, or do you exercise enough everyday?

Do you have any bad habits that may impact your health?

Good energy in the morning? Can you recover easily after some rest?

Used to feel cold, especially hands and feet?

Are you impatient? Can you bear standing in line?

Do you have high blood pressure, high cholesterol, or diabetes?

Do you take prescription drugs regularly? What kind?

Any other problems you want to share?

 

Thank you! John will respond to your email address as soon as possible.


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