All information contained in this form is confidential and will not be shared without written consent by the client.
Name (First Last) *
Gender Male Female
Address *
Email Address *
Home Phone *
Cell Phone
Current Age *
Height *
Current Weight *
Weight One Year Ago *
Would You Like Your Weight to be Different? No Yes *
Target Weight
Relationship Status Single Married Divorced Widowed *
Children? How Many?
Pets? How Many and Type?
Occupation
Hours of Work per Week
Please List Your Main Health Concerns *
Other Concerns or Goals
Serious Illness/Injuries/Hospitalizations *
Parents Health History *
Do You Sleep Well Yes No *
Sleep Hours *
Do You Wake At Night Yes No *
Please Explain
Any Pain, Stiffness, or Swelling Yes No *
Please Describe
Any Constipation, Diarrhea, or Gas Yes No *
Please Explain Any Allergies or Sensitivities (Including Foods) *
Do You Take Any Medications, Vitamins, or Supplements Yes No *
Please List
Are You Involved With Any Healers or Therapies Yes No *
How Much Time Per Week Do You Exercise 5 or More Hours Weekly 3-4 Hours Weekly 1-2 Hours Weekly None
Life Stage Pre-Menopause Menopausal Post-Menopause
Birth Control History
Discuss Any Yeast Infections or Urinary Tract Infections
Are Your Periods Regular? Yes No
How Many Days is Your Flow?
How Frequent is Your Flow?
Do You Experience Pain or Other Symptoms With Your Flow?
What Sort of Foods Did You Eat as a Child? *
What Sort of Foods do You Eat Now? *
Will Family and Friends Support Your Decision to Make Food and Lifestyle Changes? Yes No *
Do You Cook? Yes No *
What Percent of Your Food is Homecooked? *
Select Any Cravings You Have Sugar Coffee Cigarettes Salty Foods Alcohol Other
The Most Important Thing I Should Change About My Diet is *
Anything Else You Would Like to Share?
We understand and appreciate the effort and amount of time you took to fill out the questionnaires. Please allow 2 to 3 business days for us to get back to you and schedule an initial consultation.
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