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Intake Form

This is a confidential intake form that will help me to get to know you better. Please fill out the form as thoroughly as possible. Thanks!

How were you born?
Did you take a lot of antibiotics as a child?
Would you like your weight to be different:
Relationship status:
Do you sleep well at night?
How often do you experience feeling bloated?
Will family and friends be supportive of your desire to make food and/or lifestyle changes?
How are your stress levels?
Select an option
The views and nutritional advice expressed by Cecilia Ayoub are not intended to be a substitute for conventional medical services. These sessions do not claim to “cure” disease, but simply to help you make physical and mental changes in your own body in order to help your body heal itself and reach healthy fitness goals. If you suspect that you have a medical problem, promptly contact your health care provider before beginning this or any other program. Always work with a qualified health care practitioner to ensure that this complementary approach suits your specific needs. If you are currently taking any medications or have been diagnosed with any serious illness, this program may not be suitable for you.

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