Company Personal Information First Name * Email * Last Name * How often do you check your e-mails Home Phone Work Phone Mobile Phone Age Birthday Height 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, what? Social Information Relationship status Children Occupation Where do you currently live? Pets 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? What is your ancestry? What blood type are you? How is your sleep? How many hours? Do you wake up at night? Yes No Why? Any pain, stiffness or swelling? Constipation/Diarrhea/Gas? Allergies or sensitivities? Please explain Women's Health Are your periods regular? Yes No How many days is your flow? How frequent? Painful or symptomatic? Please explain Reached or approaching menopause? Please explain Birth control history Do you experience yeast infections or urinary tract infections? Please explain Medical Information Do you take any supplements or medications? Please list Any healers, helpers 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 Snacks Lunch Liquids Dinner What is your food like these days? Breakfast Snacks Lunch Liquids Dinner Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Yes No Do you cook? Yes No What percentage of your food is home-cooked? 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 Comments Anything else you would like to share? Let’s connect
