Date of Birth:
Place of Birth:
Weight Six Months Ago:
Weight One Year Ago:
Would you like your weight to be different?
If so, how?
Single Married Separated Divorced It's Complicated
If yes, how many, ages, genders, names:
If yes, how many, what kind/breed, names:
How many hours per week do you work?
Please list your main health concerns:
Other concerns and/or goals?
At what point in your life did you feel your best?
Any serious illnesses/hospitalizations/injuries?
If yes, please explain:
How is/was the heath of your mother?
How is/was the heath of your father?
What is your ancestry?
Do you sleep well?
How many hours per night?
Do you wake up at night?
If so, why?
Any pain, stiffness or swelling?
Constipation Diarrhea Gas None of the Above
If yes to the above, how often, treatment, additional information:
Allergies and/or sensitivities:
Allergies Sensitivities Both Neither
Do you take any supplements or medications?
Supplements Medications Both None of the above
If yes, please list:
Any healers, helpers or therapies with which you are involved?
What role does sports and exercise play in your life?
What foods did you eat often as a child?
What’s your food like these days?
Will friends and/or family be supportive of your desire to make food and/or lifestyle changes?
What percentage of your food is home cooked?
Do you cook?
Where do you get the rest from:
Do you crave sugar, coffee, cigarettes, or any have major additions?
If yes, please list and explain:
The most important thing I should change about my diet to improve my health is:
Anything else you’d like to share?
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