HEALTH HISTORY

First Name *

Last Name *

Email *

How often do you check email? *

Phone *

Age *

Height *

Date Of Birth *

Current Weight *

Weight 6 Months Ago *

Weight 1 Year Ago *

Would You Like Your Weight To Be Different *

Yes

If So, What Is Your Desired Weight *

SOCIAL INFORMATION

Where Do You Currently Live? *

Relationship Status *

Do You Have Children *

Yes

Do You Have Pets *

Yes

Occupation *

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 Best? *

Any Serious Illnesses/Hospitalizations/Injuries? *

How Is/Was The Health Of Your Mother? *

How Is/Was The Health Of Your Father? *

How Is Your Sleep? *

Excellent, I Always Wake Up Refreshed And Energized

Good, I Generally Get A Restful Night's Sleep

Average, I Have Occasional Difficulties Falling Or Staying Asleep

Poor, I Struggle With Frequent Sleep Disturbances

Very Poor, I Rarely Get Any Quality Sleep And Feel Exhausted Constantly

How Many Hours Of Sleep Do You Get Per Night On Average? *

Do You Wake Up At Night? *

Yes

If Yes, Why?

How Many Bowel Movements Do You Have Per Day? *

Constipation/Diarrhea/Gas? *

Any Pain, Stiffness, Or Swelling? *

Allergies Or Sensitivities? Explain Please *

WOMEN'S HEALTH

Are Your Periods Regular? *

How Many Days Is Your Flow? *

How Frequent? *

Painful Or Symptomatic? Please Explain: *

Reached Or Approaching Menopause? Explain Please: *

Birth Control History: *

Do You Experience Yeast Infections Or Urinary Tract Infections? Explain Please: *

MEDICAL INFORMATION

Do You Take Any Supplements Or Medications? List Please: *

Any Healers, Helpers, Or Therapies With Which You Are Involved? List Please: *

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

What Is Your Food Like These Days? *

Breakfast
Lunch
Dinner
Snacks
Liquids

What Is Food To You? *

Do Your Food Choices Support Your Happiness? *

Will Family And/Or Friends Be Supportive Of Your Desire To Make Food And/Or Lifestyle Changes? *

What Percentage Of Your Food Is Made At Home? *

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... *

ADDITIONAL INFORMATION

On A Scale Of 1-10 How Serious Are You About Changing Your Health & Your Life? *

Anything Else You Would Like To Share? *