Your Name (required)

Address (required)

Email Address (required)

How often do you check your email?

Telephone

Age

Height

Date of Birth

Place of Birth

Current Weight

Weight 6 Months Ago

One Year Ago

Would you like your weight to be different?
 Yes No

If so, what?

Relationship Status

Children

Pets

Occupation

Hours of Work Per Week

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 the health of your mother?

How is the health of your father?

What is your ancestry?

What blood type are you?

Do you sleep well?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas? Please explain:

Allergies or sensitivities? Please explain:

Do you take any supplements or medications? Please list:

Any healers, helpers or therapies with which you are involved? Please list:

What role does sports and exercise play in your life?

What foods did you eat often as a child?
Breakfast

Lunch

Dinner

Snacks

Liquids

What's your food like these days?
Breakfast

Lunch

Dinner

Snacks

Liquids

Will family and/or friends 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 have any major addictions?

The most important thing I should change about my diet to improve my health is:

Anything else you want to share?