Personal Information

    First Name (required)

    Email Address (required)

    Last Name (required)

    Phone Number (required)

    Physical Information

    Age

    Place of Birth

    Birthdate

    Height

    Weight six months ago

    Would you like your weight to be different?

    YesNo

    Current Weight

    Weight one year ago

    If so, what is your desired weight?

    Social Information

    Relationship Status

    Children

    Occupation

    Where do you currently live?

    Pets

    Hours of work per week

    Health Information

    Please list your main health concerns

    Other concerns an/or goals?

    At what point in your life did you feel your best?

    What is your ancestry?

    How is/was the health of your mother?

    How is your sleep?

    Do you wake up at night?

    Any pain, stiffness, or swelling?

    What blood type are you?

    How is/was the health of your father?

    How may hours?

    Why?

    Constipation, diarrhea, or gas?

    Any serious illnesses, injuries, or hospitalizations?

    Any allergies or sensitivities?

    Medical Information

    Do you take any supplements or medications? Please list

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

    What role do sports and exercise play in your life?

    Food Information

    What foods did you eat often as a child?

    Breakfast

    Lunch

    Dinner

    Snacks

    Liquids

    Do you cook?

    YesNo

    What is your food like these days?

    Breakfast

    Lunch

    Dinner

    Snacks

    Liquids

    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? Please list

    Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

    What is the most important thing that you would like to do to improve your health?

    Additional Comments

    Is there anything else that you would like to share?