Personal Information


First Name:*

Last Name:*

Email:*

How often do you check e-mail:

Home Phone:

Work Phone:

Mobile Phone:

Age:

Height:

Birthdate:

Place of Birth:

Current Weight:

Weight six months ago:

Weight one year ago:

Would you like your weight to be different?:

If so, what?:

Social Information


Relationship Status:

Where do you currently live?:

Children:

Pets:

Occupation:

Hours of work per week:

Health Information


Please list your main health concerns:

Other concerns and/or goals?:

At what point in your life did you feel best?:

Any serious illnesses/hospitalizations/injuries?:

How is/was the health of your mother?:

How is/was the health of your father?:

What is your ancestry?:

What blood type are you?:

How is your sleep?:

How many hours do you sleep?:

Do you wake up at night?:

Why?:

Any pain, stiffness or swelling?:

Constipation/Diarrhea/Gas?:

Allergies or sensitivities? Please explain:

Are your periods regular?:

How many days is your flow?:

How frequent?:

Painful or symptomatic? Please explain:

Reached or approaching menopause? Please explain:

Birth control history:

Do you experience yeast infections or urinary tract infections? Please explain:

Medical Information


Do you take any supplements or medications? Please list:

Any healers, helpers or therapies with which you are involved? Please list:

What role do sports and exercise play in your life?:

Food Information


What foods did you eat often as a child?:
Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?:

Do you cook?:

What percentage of your food is home-cooked?:

Where do you get the rest from?:

Do you crave sugar, coffee, cigarettes, or have any major addictions?:

The most important thing I should do to improve my health is:

What is your food like these days?:
Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Additional Comments


Anything else you would like to share?:


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