Name

First Name

Last Name

Email Address

Mobile:

Age

Height

Birthday

Place of Birth

Current weight

Weight six months ago

Would you like your weight to be different?

If so what?

Relationship status

Where do you currently live?

Children:

Pets:

Occupation:

Hours of work per week:

Please list your main health concerns:

Any pain stiffness or swelling?

Other concerns and/or goals?

Allergies or sensitivities? Please explain:

At what point in your life did you feel best?:Any

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?:

What blood type are you?:

How is your sleep?

How many hours?

Do you wake up at night? why?

Any healers, helpers or therapies with which you are involved?

What role do sports and exercise play in your life?:

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?:

Where do you get the rest from?:

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

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

Anything else you would like to share?:

Are your periods regular?:

How many days is your flow?: