Personal Information

Name

Address

Email

How often do you check mail

Home Phone

Work Phone

Cell Phone

Age

Height

Birthdate

Place of Birth

Current Weight

Weight six months ago

Weight 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?

At what point in your life did you feel best?

Any serious illness/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?

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

Do you experience yeast infections or urinary tract infections? Please explain

Medical Information

Please List any supplements and/or medications you take

Please List any healers, pets, or therapies with which you are involved

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

What’s your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Will family and/or friends be supportive in 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?

Important thing I should change about my diet to improve my health is

Additional Comments

Anything else you would like to share?