First Name (required)
Last Name (required)
Your Email (required)
How often do you check email?
Home Phone:
Work Phone:
Mobile Phone:
Age:
Height:
Birth Date:
Place of Birth
Current weight
Weight 6 months ago
Weight one year ago
Would you like your weight to be different?
If so, what?
Relationship Status
Where do you currently live?
Children:
Pets:
Occupation:
Hours of work per week?
Please list your main health concerns:
Other concerns and/or goals:
At what point in your life did you feel best?
Any serious illness/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 wake up at night?
Why?
Any pain, stiffness or swelling?
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:
Constipation/Diarrhea/Gas?
Allergies or sensitivities? Please explain:
Do you take any supplements or medications?
Any healers, helpers or therapies with which you are involved? Please list:
What role do sports and exercise play in your life?
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:
Anything else you would like to share?
