Name *
Address
Home Phone *
Mobile phone
Work Phone
Age
Height
Birthdate
Current Weight
Weight six months ago
Would you like your weight to be different?Please SelectYesNo
If so, what?
Relationship Status
ChildrenPlease SelectYesNo
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 illness/hospitalizations/injuries
How is/was the health of your mother?
How is/was your father’s health?
What is your ancestry?
Are you in Menopause or reaching that stage? Please explain. (If yes, skip the next 5 questions.)
Are your periods regular?Please selectYesNo
How many days is your flow?
How frequent?
Painful or symptomatic?Please selectYesNo
Please explain
Birth control history
Do you experience yeast infections or urinary tract infections? Please explain
What blood type are you?
Do you sleep well?Please SelectYesNo
How many hours?
Do you wake up at night?Please SelectYesNo
Why?
Any pain, stiffness or swelling?
Constipation/Diarrhea/Gas? Please explain
Allergies or sensitivities? Please explain
Do you take any supplements or medications?Please SelectYesNo
Please list
What role does exercise play in your life?
Any healers, helpers, pets or therapies with which you are involved?Please SelectYesNo
Please List
What is your food like these days? Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?Please SelectYesNo
Do you cook?Please SelectYesNo
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 change about my diet to improve my health is:
Anything else you would like to share?
How did you hear of me?
E-Mail *
