First Name: *
Last Name: *
Preferred Contact Method:
Place of Birth:
Weight six months ago:
Weight one year ago:
Would you like your weight to be different?
If so, how?
Where do you currently live?
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/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?:
If so, why?
Any pain, stiffness or swelling?
Allergies or sensitivities? Please explain:
Are your periods regular?:
How many days is your flow?:
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:
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?
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:
Anything else you would like to share?:
Please enter your full name to sign the form: