First Name
Last Name
Age
Height (feet/inches)
Date of Birth
Place of Birth
Email
Do you prefer contact via phone or email?
Mobile Phone
Home Phone
Work Phone
Current Weight (lbs)
6 months ago
12 months ago
Would you like your weight to be different?
If so, how?
Relationship Status
Where Do You Live?
Do you have children?
Do you have pets?
Occupation
How Many Hours Do You Work Per Week?
What are your main health concerns?
Any other concerns and/or goals?
At what point in your life did you feel your best?
Any current or previous serious illnesses, hospitalizations, or injuries?
Are there any other health conditions you'd like to discuss?
How is your sleep?
How many hours do you sleep per night?
Do you wake up during the night? If so, why?
Any pain, stiffness, or swelling?
Any constipation, diarrhea, or gas?
Any allergies or sensitivities?
Are your periods regular?
How many days is your flow?
How frequent?
Are your periods painful or symptomatic? If so, please explain.
Do you take birth control, or hormones for birth control or menopause symptoms? If so, for how long?
Do you experience yeast infections or urinary tract infections? If so, please explain.
List all supplements and/or medications you take
Are you involved with any healers, helpers, or therapies? If so, what?
What role do sports and exercise play in your life?
Will your family and 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 does your non-home-cooked food come from?
As a CHILD, what foods did you eat for Breakfast?
... for Lunch?
... for Dinner?
... for Snacks?
... Liquids?
As an ADULT what foods do you eat for Breakfast?
... for Lunch?
... for Dinner?
... Snacks?
... Liquids?
Do you crave any of the following? Select all that apply.
sugar
coffee
cigarettes
other tobacco products
vape or marijuana products
alcohol
none of the above
Do you have cravings for anything not listed above?
What is the most important thing you should change about your diet to improve your health?
Is there anything else you would like to share?
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