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 and/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?

Are your periods regular?

How frequent?

What blood type are you?

How is/was the health of your father?

How may hours?

Why?

Constipation, diarrhea, or gas?

How many days is your flow?

Painful or symptomatic? Please explain

Have you reached or are you reaching menopause? Please explain

Birth control history

Do you experience yeast infections or urinary tract infections? Please explain

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?