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Personal Information

First Name:

Last Name:

Email Address:

How often do you check mail:

Home Phone:

Cellular Phone:

Work phone:

Address:

Age:

Height:

Birthdate:

Place of Birth:

Current Weight:

Weight six months ago:

One Year Ago:

Would you like your weight to be different?:

If so what?:

Social Information

Relationship status:

Children:

Pets:

Occupation:

Hours of work per week:

Health Information

Please list your main health concerns:

Other concerns and/or goals?:

Any serious illness/hospitalizations/injuries:

At what point in your life did you feel best:

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?:

Allergies or sensitivities? Please explain:

Are your periods regular?:

How many days is your flow?:

How frequent?:

Painful or symptomatic?:

Please explain::

Reaching or Approaching Menopause? Please explain:

Birth control history:

Vaginal infections, reproductive concerns?:

Medical Inforamtion

Do you take any supplements or medications?:

Please List::

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

Please List:

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’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?:

Do you cook?:

What percentage of your food is home cooked?:

What percentage is not?:

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 would like to share?:

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