First and Last Name
*
First Name
Last Name
Email
How often do you check email?
Best phone # to reach you at
*
(###)
###
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Age
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Height
Birthdate
MM
DD
YYYY
Place of Birth
Current Weight
Weight 6 months ago
One year ago
Would you like your weight to be different?
If yes, what would you like it to be?
Relationship Status
Where do you currently live?
Children:
Occupation:
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 best?
Any serious illnesses, hospitalizations or injuries?
How is / was the health of your mother?
How is / was the health of your father?
How is your sleep?
How many hours?
Do you wake up at night?
If yes, why?
What is your morning routine?
What is your nighttime routine?
Any pain, stiffness or swelling?
Constipations, diarrhea, gas, or digestive issues?
Allergies or sensitivities? Please explain:
Have you been tested for food allergens?
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, movement, and exercise play in your life?
How are your stress levels?
What methods do you use to relieve your stress?
What do you do each day to fuel your mind, body, and life?
Breakfast
Lunch
Dinner
Snacks
Liquids
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 or you think I need to know?
