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First and Last Name

 
Do you have Netflix?

     
 
What is your time zone?

 
List a few dates/times for our call in the next 2 weeks.

 
How often do you check email?

 
Age

 
Height

 
Birthdate

 
Place of birth

 
Current weight

 
Weight 6 months ago

 
Weight 1 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 and/or goals?

 
At what point in your life did you feel your 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?

 
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.

 
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? Please list what you normally consumed for breakfast, lunch, dinner, snacks and liquids.

 
What is your food like these days? Please list what you normally consume for breakfast, lunch, dinner, snacks and 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:

 
Anything else you would like to share?

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