Personal Information


First Name


Last Name


Email


How often do you check your email?
Often Sometimes Rarely

Home Phone


Work Phone


Mobile Phone


Age


Height


Date of Birth


Place of Birth


Current weight


Weight six months ago


One year ago


Would you like your weight to be different?


If so, what?




Social Information


Relationship status


Where do you currently live?


Children


Pets


Occupation


Hours of work per week




Health Information


Please list your main health concerns.


Other concerns and/or goals?


At what point in your life did you feel your 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?


Do you wake up at night?


Why?


Any pain, stiffness, or swelling?


Constipation/Diarrhea/Gas?


Allergies or sensitivities? Please explain.


Please select from one of the following.



Medical Information


Do you take any supplements or medications? Please list.


Any helpers, healers, or therapies with which you are involved? Please list.


What role do sports and exercises play in your life?




Food Information


What foods did you eat often as a child?
Breakfast

Lunch

Dinner

Snacks

Liquids


What is your food like these days?
Breakfast

Lunch

Dinner

Snacks

Liquids


Will family/friends be supportive of your desire to make food/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:




Additional Comments


Anything else you would like to share?




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