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Change Your Life with Food Health History
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First and Last Name
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Your answer
Email
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Your answer
Mobile Phone Number
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Your answer
Current weight, weight 6 months ago, weight one year ago?
Your answer
Would you like your weight to be different than it is today? What would you like your weight to be?
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Your answer
Social Information
Relationship status
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Married
Single
Divorced
Other
What is your current address?
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Your answer
Do you have children, pets? If yes, how many
Your answer
What is your occupation and the number of hours per week that you work?
Your answer
HEALTH INFORMATION
Please list your 2 main health concerns at this time.
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Your answer
What are your other concerns and health goals?
Your answer
At what point in your life did you feel your best and why?
Your answer
Have you had any serious illnesses/hospitalizations/injuries? Please explain.
Your answer
HEALTH INFORMATION HISTORY
How is/was the health of your mother?
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Your answer
How is/was the health of your father?
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Your answer
What is your ancestry?
Your answer
How is your sleep? How many hours do you sleep? Do you wake up at night and why?
Your answer
Any pain, stiffness or swelling? and where?
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Your answer
How is your digestion and elimination?
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Your answer
Any allergies or food sensitivities? Please explain.
Your answer
MEDICAL INFORMATION
Please list all supplements and medications you are currently taking.
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Your answer
Do you use any healers or therapies currently? Please list.
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Your answer
What role does exercise play in your life?
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Your answer
Please give me a typical day of food like you are currently eating? Breakfast, Lunch, Dinner and Snacks
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Your answer
What percentage of your meals do you home cook?
10%
20%
40%
50%
75%
100%
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What is your food secret or vice, what do you crave?
Your answer
What do you think is the most important thing you can do to improve your health?
Your answer
When do you feel the most likely to eat something you should not eat? What time of day/what situation. Please be specific.
Your answer
Please share anything else you would like to share below that you think I should know about your health.
Your answer
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