Halfway Revisit OrganycLove Form

All of your information will remain confidential between you and Sandrina Bencomo.

Please complete the form below:

Full Name:

First Name

Last Name

What overall positive changes in your health and well-being have you noticed since starting your 6-month program?

What goals have been met?

Are there areas you would like to focus on, shift, or approach differently in order to meet your goals?

What recommendations did you find helpful and which do you continue to use?

What is your main concern/goal at this time?

Any other comments?

Any changes with weight?

How is your sleep?

Constipation or diarrhea?

How is your mood?

Are you exercising?

How many glasses of water do you drink a day?

What percentage of your foods do you cook/prepare at home?

What’s your diet like these days? Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

What supplements and medications are you currently taking?