Personal Information First Name Last Name Email How often do you check your email? Home MobileAge HeightBirthdate MM slash DD slash YYYY Place of Birth Current Weight Weight 6 months ago Weight 1 year ago Would you like your weight to be different? Yes No What would you like your weight to be? Social Information Relationship Status Where do you currently live? Children Yes No Pets Yes No Occupation Hours of work per week? Health Information Please list your main health concernsOther concerns or goalsAt what point in your life did you feel best?Any serious illnesses, hospitalizations, or injuries?How is/was the health of your mother?How is/was the health of your father?What is your ancestry? What is your blood type? How is your sleep? How many hours do you sleep on average per night? Do you wake up at night? If you wake up at night, why? Any pain, stiffness, or swelling? Do you experience constipation, diarrhea, or gas? Do you have any allergies or sensitivities? Please explainMedical Information Do you take any supplements or medications? Please listAny healers, helpers, or therapies with which you are involved? Please ListWhat role do sports and exercise play in your life?Food Information What foods did you eat often as a child for Breakfast?What foods did you eat often as a child for Lunch?What foods did you eat often as a child for Dinner?What foods did you eat often as a child for Snacks?What liquids did you consume often as a child?What is your food like currently? (Breakfast)What is your food like currently? (Lunch)What is your food like currently? (Dinner)What is your food like currently? (Snacks)What liquids do you consume most often currently?Will family and friends be supportive of your desire to make food and lifestyle changes?Do you cook? Yes No What percentage of your food is home-cooked?Where do you get the rest of your food from?Do you crave sugar, coffee, cigarettes, or have any major addictions?The most important thing I should do to improve my health isAdditional Information Anything else you would like to share?
