Personal Information

Name:
Address:
Email:
How often do you check mail:
Home Phone:
Work Phone:
Cell Phone:

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?:

Social Information

Relationship status:
Children?:
Pets?:
Occupation:
Hours of work per week:

Health Information

Please list your main health concerns:
Other concerns and/or goals?:
At what point in your life did you feel best:
Any serious illness/hospitalizations/injuries:
How is the health of your mother?:
How is the health of your father?:
What is your ancestry?:

What blood type are you?:
Do you sleep well?:
How many hours?:
Do you wake up at night?:
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:
Reaching or Approaching Menopause? Please explain:

Birth control history:
Vaginal infections, reproductive concerns?:

Medical Information

Do you take any supplements or medications?:
Please List:

Any healers, helpers, pets or therapies with which you are involved?:
Please List:
What role do sports and exercise play in your life?:

Food Information

What foods did you eat often as a child?
Breakfast	Lunch
Dinner	Snacks
Liquids

What’s your food like these days?
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?:
What percentage is not?:
Where do you get the rest from?:
Do you crave sugar, coffee, cigarettes, or have any major addictions?:
The most important thing I should change about my diet to improve my health is:

Additional Comments

Anything else you would like to share?: