Name
*
First Name
Last Name
Preferred Pronouns
Email
*
Phone
*
(###)
###
####
Preferred Method of Communication
*
Email
Text
Phone Call
Date of Birth
*
MM
DD
YYYY
Age
*
Height
*
Would you like your weight to be different?
*
Yes (Please complete the next four questions.)
No (Feel free to skip the next three questions if you wish.)
Maybe (Please complete the next four questions.)
How would you like your weight to be different?
Current Weight
Weight Six Months Ago
Weight One Year Ago
Relationship Status
*
Where do you live?
*
Any children and/or fur babies?
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Occupation
*
How many hours do you work per week?
What are your main health concerns?
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Any other concerns and/or goals?
At what point in your life did you feel your best?
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How is/was your mother's health?
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How is/was your father's health?
*
What is your ancestry?
How is your sleep?
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How many hours do you sleep per night?
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Do you wake up during the night? If so, why?
Any pain, stiffness or swelling?
Any constipation, diarrhea or gas?
Any allergies or sensitivities?
Are your periods regular?
Yes
No
How many days and how frequent is your flow?
Are your periods painful or symptomatic? If so, please explain.
Have you reached or are you approaching menopause? If so, please explain.
What is your birth control history?
Do you experience yeast infections or urinary tract infections? If so, please explain.
List all supplements or medications.
Are you involved with any healers, helpers, therapists, etc? If so, please explain.
Any current or previous serious illnesses, hospitalizations or injuries?
What role do sports and exercise play in your life, if any?
Will your family and friends be supportive of your desire to make food and/or lifestyle changes?
How much water do you drink each day, on average?
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What, if any, percentage of your food is home-cooked?
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Where does your non-home-cooked food come from?
What foods did you eat often as a child? (Think meals, snacks and drinks.)
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What foods do you typically eat now? (Think meals, snacks and drinks.)
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Do you experience any cravings or addictions? If yes, please explain to the extent you're comfortable.
What do you feel is the most important thing you need to change about your diet and/or lifestyle to improve your health?
Is there anything else you would like to share?
