Your
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Age: |
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Address: |
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Height: |
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E-mail
Address: |
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Birthdate: |
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How often do you check email?: |
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Place of Birth: |
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Home Phone: |
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Current Weight: |
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Work Phone: |
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Weight six months ago: |
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Cell Phone: |
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Weight one year ago: |
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Would you like your weight to be different?: |
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If so, what?: |
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Social Information
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| Relationship Status: |
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Children: |
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| Occupation: |
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Pets: |
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| Hours per Week: |
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Health Information
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| Please list your main health concerns: |
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What blood type are you?: |
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| Other concerns and/or goals?: |
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Do you sleep well?: |
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| At what point in your life did you feel best: |
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How many hours?: |
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| Any serious illness, hospitalizations, or injuries: |
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Do you wake up at night?: |
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| How is the health of your mother?: |
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Why?: |
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| How is the health of your father?: |
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Any pain, stiffness or swelling?: |
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| What is your ancestry?: |
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Constipation, Diarrhea, or Gas?: |
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Allergies or sensitivities?
Please explain:
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| Are your periods regular?: |
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Reaching or Approaching Menopause? Please explain: |
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| How many days is your flow?: |
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Birth control history: |
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| How frequent?: |
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Vaginal infections,
reproductive concerns?: |
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| Painful or symptomatic?: |
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| Please explain: |
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Medical Information
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| Do you take any supplements or medications?: |
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Any healers, helpers, pets or therapies with which you are involved?: |
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| Please List: |
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Please List: |
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| What role do sports and exercise play in your life?: |
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Food Information |
| What foods did you eat often as a child? |
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What’s your food like these days? |
| Breakfast |
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Breakfast |
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| Lunch |
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Lunch |
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| Snack |
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Snack |
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| Dinner |
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Dinner |
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| Liquids |
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Liquids |
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| Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? |
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Do you cook?: |
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| What percentage of your food is home cooked?: |
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What percentage of your is not home cooked?: |
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| Where do you get the rest from?: |
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Do you crave sugar, coffee, cigarettes, or have any major addictions?: |
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| The most important thing I should change about my diet to improve my health is: |
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Additional Comments |
| Anything else you would like to share?: |
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