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Home
Supplements
Kangen Water
Coaching
About Us
Contact
- Contact Us
Subscribe
Testimonials

contact

contact

address

233 West State Street
Eagle, Idaho 83616

phone

emails

David Cruz
DRCruz@TheKetogenicReset.com

Lauren Sassadeck-Cruz
LGCruz@TheKetogenicReset.com

hours

Monday-Thursday
10 AM-7 PM

Friday
10 AM-5 PM

Saturday & Sunday
by appointment only

Schedule a Complimentary Consultation

TKR Questionnaire

Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

Date of Birth

MM slash DD slash YYYY

Age

Phone(Required)

Untitled

Email(Required)

BP

Height

Body Fat %

Level of Activity

Sedentary

Lightly Active

Moderately Active

Very Active

Main Concerns/Health Goals(Required)

Weight in the past 5 years

List current weight, most weight, least weight, goal weight

What is your body type - where do you hold most of your fat

Sagging Belly

Protruding Belly

Hips & Thighs

All Over

What kind of water do you drink? Filtered/Natural Spring/Other

How long has it been since you were at a comforable weight?

on a scale from 1 -10 how commited are you to achieving. your goals?

Medications / For What / Who Recommended / How Long? History of: Antibiotics/ Antacids / PPIs / Birth Control or Hormone replacement

History of Parasites, Mold or Fungus: Y/N What kind?

If you knew that an enema could help you achieve your health goal and weight goal faster, would you be willing to do it?

Yes

No

Supplements / For What / Who Recommended / How Long?:

Birth and early years: How was s/he born? Breastfed? Mom’s health? Siblings? Health in infancy and early childhood? Sick often? Ear infections? Antibiotics? HS / College Nutrition & Health?

Heart Health: Heart Palpitations or rhythmic abnormalities? Hx of Cardiovascular event? Blood Pressure?

Life Circumstance: Work / Career - Love it? Family / Relationships - Love them? Or source of stress? Supportive of your health?

Medical History: Respiratory: Asthma? Seasonal Allergies? Pneumonia? Ear Infections?

Immune System: # of times / year sick? How long to recover?

Digestion / Acid Reflux / Gut issues

Skin: Rosacea, Eczema, Psoriasis, Auto-immune?

Musculoskeletal: Joint pain, skeletal issues, soft tissue pain, weak muscle or chronic pain? Major Surgeries? Traumatic accidents?

Sleep / Energy / Stress

Pre/Peri/Postmenopause

Testosterone

Liver issues?

Do you have a Gall Bladder? Any issues?

Thyroidism

Diet & Exercise

Readiness for change: What would it look like once you’re successful?

ANY OTHER CONCERNS OR HEALTH ISSUES?

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contact us

233 West State Street
Eagle, Idaho 83616

Complimentary Consultation

hours

Monday-Thursday
10 AM-7 PM
Friday
10 AM-5 PM
Saturday & Sunday
by appointment only

Recipes

Truly Keto Pastries
Ketogenic Reset Cookbook

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