Name
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First Name
Last Name
Age
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Date of Birth
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Place of Birth
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Height
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Current Weight
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Weight one year ago
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Would you like your weight to be different?
Yes
No
If so, how?
Relationship Status
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Where do you live?
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Do you have children?
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Do you have pets?
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Occupation
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How many hours do you work per week?
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What about your health/lifestyle would you most like to change?
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Any current or previous serious illnesses, hospitalizations, or injuries?
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How is/was your mother's health?
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How is/was your father's health?
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What is your ancestry?
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How is your sleep?
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How many hours of sleep do you usually get per night?
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Do you wake up during the night? If so, why?
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Do you have pain, stiffness or swelling?
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Any constipation, diarrhea or gas?
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Do eating some foods cause discomfort (gas, bloating, pain)? Do you know which foods?
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What is your blood type?
Are your periods regular?
If no periods, please explain
How many days is your flow?
How frequent?
Are your periods painful or symptomatic? If yes, 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 medicines:
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Are you involved with any healers, helpers or therapies?
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What role do sports and exercise play in your life?
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Do you cook?
What percentage of your food is home-cooked?
Where does your non-home-cooked food come from?
What kinds of foods/drinks did you eat as a child?
What do you typically eat for breakfast now?
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What to you typically eat for lunch now?
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What to you typically eat for dinner now?
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What kind of snacks do you typically eat now?
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What kind of beverages do you typically drink now?
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Do you crave sugar, caffeine or cigarettes? Do you have any other major addictions?
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Is there anything else you would like to share?
