Personal Information

    How often do you check e-mail:

    Home Phone: Numbers Only
    Work Phone: Numbers Only
    Mobile Phone: Numbers Only
    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?:

    Relationship status:
    Where do you currently live?:
    Children:
    Pets:
    Occupation:
    Hours of work per week:

    Please list your main health concerns:
    Other concerns 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?:
    How is your sleep? How many hours?:
    Do you wake up at night? If so, why?:
    Any pain, stiffness or swelling?:
    Constipation or diarrhea?:
    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 do sports and exercise play in your life?:


    What foods did you eat often as a child?

    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?:
    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:

    What is your food like these days?

    Breakfast:
    Lunch:
    Dinner:
    Snacks:
    Liquids:


    Anything else you would like to share?: