Personal Info

Suggest a few brief sentences here to explain/describe the purpose, questions, etc.

Personal Information Form

First Name:

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Email Address (required)(Required)

How often do you check your email?

Home Phone:

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Current Weight:

Would you like your weight to be different? If so what weight?:

Relationship Status:

Number of children (if any):

Any Pets? (If so explain):

Occupation:

Hours of Work Per Week:

Please List Your Main Health Concerns:

Other Concerns 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?:

Blood Type:

How is your sleep?:

How many hours do you sleep?:

Do you wake up at night? If so explain:

Any pain, stiffness, or swelling?:

Constipation / diarrhea / gas?:

Any allergies or sensitivities?:

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?:

Do you cook?:

What food did you eat as a child? (Breakfast, Lunch, Dinner, Snacks, Liquids):

Will family and / or friends be supportive of your desire to make food and / or lifestyle changes?:

What percentage of your food is homecooked?:

Do you crave sugar, coffee, cigarettes, or have any major addictions?:

Where do you get the rest of your food?:

Do you crave sugar, coffee, cigarettes, or have any major addictions?:

What is your food like these days? (Breakfast, Lunch, Dinner, Snacks, Liquids):

The most important thing I should do to improve my health is:

Additional Comments:

Phone

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