Email *
Home phone: *
Work phone:
Mobile Phone:
Age: *
Birthdate: *
Place of birth: *
Height: *
Current Weight: *
Weight Six Months Ago: *
Weight One Year Ago: *
Would you like your weight to be different?: *
If so, what?: *
What is your current relationship status?: *
Where do you currently live?: *
Do you have children?: *
Do you have any pets?: *
What is your occupation?: *
How many hours a week do you work?: *
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 is your blood type?: *
How is your sleep?: *
How many hours a night?: *
Do you wake up at night?: *
Why are you waking up?: *
Any Pain, Stiffness, or Swelling?: *
Constipation, Diarrhea, or Gas?: *
Allergies or sensitivities? 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?: *
What is your food like these days?: *
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?: *
