First Name
Last Name
Email
How often do you check e-mail? EverydayEvery 2-3 daysOnce a week
Home phone
Work phone
Mobile phone
Age
Height
Birthdate (YYYY/MM/DD)
Place of Birth
Current weight
Weight 6 months ago
Weight 1 year ago
Would you like your weight to be different?
If so what
Relationship Status SingleIn a RelationshipEngagedMarriedIt's complicatedWidowedSeparated
Children 0123455+
Where do you currently live?
Pets yesno
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 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? 0+0-A+A-B+B-AB+AB-I don't know
How is your sleep?
How many hours?
Do you wake up at night? YesNo
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
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?
What foods did you eat often as a child? Breakfast, Lunch, Dinner, Snacks and Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook? YesNo
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 and Liquids
Anything else you would like to share?
