First Name:
Last Name:
Full Address:
Email Address:
Contact Numbers: Work: Home: Cell:
Age:
Height:
Blood Type:
Date of Birth:
Place of Birth:
Current Weight:
Weight Six Months Ago:
Weight One Year Ago:
Would you like your weight to be different? Yes No
If so, how?
Relationship Status: Single Married Separated Divorced It's Complicated
Children: Yes No
If yes, how many, ages, genders, names:
Pets: Yes No
If yes, how many, what kind/breed, names:
Occupation:
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? Yes No
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? Yes No
How many hours per night?
Do you wake up at night? Yes No
If so, why?
Any pain, stiffness or swelling? Yes No
Constipation/Diarrhea/Gas? 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? Yes No
What role does sports and exercise play in your life?
What foods did you eat often as a child?
Breakfast:
Lunch:
Dinner:
Snacks:
What’s your food like these days?
Will friends and/or family be supportive of your desire to make food and/or lifestyle changes? Yes No
What percentage of your food is home cooked?
Do you cook? Yes No
Where do you get the rest from:
Do you crave sugar, coffee, cigarettes, or any have major additions? Yes No
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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