Online Forms
____________________________________________________________

Contact Information

Personal Information

First Name : *
Last Name : *
Email : *
Home Phone : *
Address Street 1 :
Address Street 2 :
City :
State:
Zip Code : (5 digits)
How often do you check e-mail ?
Work Phone:
Mobile Phone :
Age :
Height :
Place of Birth :
Current Weight :
Weight six months ago :
One year ago :
Would you like your weight to be different?
If so what?
Social Information

 
Realaltioship Status :
Children :
Pets:
Occupation:
Hours of work per week:
 
Health Information

 
Please list your main health concerns:
Other concerns and/or goals ?:
At what point in your life did you feel best:
Any serious illness/ hospitalization/ 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?:
Do you sleep well?:
How many hours?:
Do you wake up at night?:
Why?:
Any pain, stiffness or swelling?:
Constipation/ Diarrhea/ Gas?:
Allergies or sensitivities? Please explain:
Are your periods regular?:
How many days is your flow?:
How frequent?:
Painful or symptomatic?:
Please explain?:
Medical Information

 
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?:
Food Information

 
What food did you eat often as a child?
 
Breakfast?:
Lunch:
Dinner:
Snack:
Liquid:
What food do you eat these days?

 
Breakfast:
Lunch:
Dinner:
Snack:
Liquid:
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?:
What percentage is not?:
Where do you get the rest from?:
Do you crave sugar, coffee, cigarettes, or have any major addictions?:
The most important thing I should change about my diet to improve my health is:
 Additional Comments

 
Anything else you would like to share?: