Name: *

Address

Address:

Email: *

Work Phone #

Cell Phone #

Age:

Height:

Birthday:

Current Weight/Weight Long Ago:

Relationship Status:

Would you like your weight to be different? If So, What?

Children?

Occupation:

Please list your main health concerns:

Other concerns and/or goals:

At what point in your life did you feel best:

Any serious illness/hospitalization/injuries:

How is/was the health of your mother?

How is/was the health of your father?

What blood type are you?

Do you sleep well?

How many hours do you sleep?

Do you wake up at night? Why?

Any pain, stiffness, or swelling?

Constipation/Gas? Please explain:

Allergies or sensitivities?? Please explain:

Are your periods regular?

Birth Control History?

Painful or Symptomatic? Please explain:

Reaching or approaching menopause? Please explain:

What your experience? Please explain:

Do you take any supplements or medications? Please List:

What role do sports and exercise play in your life?

What's your food these days? List Breakfast Lunch Dinner, Snacks, and Liquids:

What percentage of your food is home-cooked? Where do you get the rest from?

Do you crave sugar, coffee 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?

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