Contact Us info@teritom.com Assessment Form Please complete this form and submit before your appointment. Name * First Name Last Name Email * Phone (###) ### #### How did you hear about us? Why are you seeking nutritional/wellness counseling? Do you have any medical conditions such as diabetes or prediabetes, heart disease, hypertension, high cholesterol, asthma, etc? Please list any medications you are currently taking. Physician's Name First Name Last Name Physician's Phone (###) ### #### Do you have any other inflammatory issues like joint pain, brain fog, skin conditions, GI distress, impaired vision, headaches, etc? How would you rate your sleep? How would you rate your overall stress level? Do you drink alcohol or caffeinated beverages? If so, how often? Do you smoke? What do you eat on a typical day and at what times do you usually eat? Do you go long periods without eating? What do you currently do for exercise? How many hours a day do you look at screens--phones, tablets, televisions, computers? Do you use any kind of blue light blocking glasses or other protection? Please write any other pertinent information. Thank you!