How often do you check your email?
Date of Birth
Place of Birth
Weight six months ago
One year ago
Would you like your weight to be different?
If so, what?
Where do you currently live?
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 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?
Any pain, stiffness, or swelling?
Allergies or sensitivities? Please explain.
Please select from one of the following.
Are your periods regular?
How many days is your flow?
Painful or symptomatic? Please explain.
Reached or approaching menopause? Please explain.
Please provide your birth control history.
Do you experience yeast infections or urinary tract infections? Please explain.
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?
What foods did you eat often as a child?
What is your food like these days?
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:
Anything else you would like to share?
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