Personal Info Suggest a few brief sentences here to explain/describe the purpose, questions, etc. Personal Information Form First Name: Untitled Email Address (required)(Required) How often do you check your email? Home Phone: Untitled Untitled Untitled Untitled Untitled Untitled Untitled 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?: 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:CommentsThis field is for validation purposes and should be left unchanged.