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First Name
*
Last Name
*
Email Address
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How often do you Check e-mail?
Cell Phone Number
Other Phone Number
Age
Height
Birthday
Place of Birth
Current Weight
Weight Six 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
Average Hours of Work Per Week
Please list your main health concerns:
Any Pain or Stiffness?
Constipation/Diarrhea/Gas?
Allergies or sensitivities? Please Explain
Are Your Periods Regular?
How many days is your flow?
How frequent is your period?
Are your periods painful or symptomatic? If yes, please explain.
Have You Reached or approaching Menopause? Please explain.
Birth control history:
Do you experience yeast infections or urinary tract infections? Please explain:
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?:
Select a Choice
Why?
Do you take any supplements or medications? Please list:
Any healers, helpers or therapies with which you are involved?
What role do sports and exercise play in your life?:
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
Lunch:
Dinner:
Breakfast:
Snacks:
Liquids:
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
What percentage of your food is home-cooked?:
Do you cook?:
Do you crave sugar, coffee, cigarettes, or have any major addictions?
Where do you get the rest from?:
Are You Happy? If no, please explain why.
Anything else you would like to share?:
The most important thing I should do to improve my health is:

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