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Height
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Current Weight
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Weight six months ago
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Weight one year ago
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Would you like your weight to be different?
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If so, what is your ideal weight?
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Where do you currently live?
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Family/Living Situation
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Children
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Pets
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Occupation
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Hours of work per week:
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Please list your main health concerns:
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Other health concerns and/or goals?:
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Exercise/Recreation:
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At what point in your life did you feel best?
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Any serious illnesses/hospitalizations/injuries?
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How is/was the health of your mother?
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How is/was the health of your father?
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What is your ancestry?
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How is your sleep? How many hours?
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What role does exercise play in your life?
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Rate each of the following symptoms using the following point scale:
0 — Never or almost never have the symptoms
1 — Occasionally have it, effect is not severe
2 — Occasionally have it, effect is severe
3 — Frequently have it, effect is not severe
4 — Frequently have it, effect is severe
Fatigue
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Congestion
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Excess Weight
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Brain Fog
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IBS/Bloating
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Constipation
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Diarrhea
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Reflux
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Headaches
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Joint Pain
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Itchy Skin
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2
3
4
Sweet Cravings
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0
1
2
3
4
Sleeplessness
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0
1
2
3
4
Do you take any supplements or medications? Please list:
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Any healers, helpers or therapies with which you are involved? Please list:
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Do you have any known food allergies or sensitivities?
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What foods did you eat often as a child?
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Breakfast:
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Lunch:
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Dinner:
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Snacks:
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Liquids:
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What is your food like now on a “good day?”
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Breakfast:
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Lunch:
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Dinner:
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Snacks:
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Liquids:
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What is your food like now on a “bad day?”
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Breakfast:
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Lunch:
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Dinner:
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Snacks:
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Liquids:
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What foods do you crave?
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What do you want to change about how you look and feel?
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How important is this to you - on a scale of 1-10?
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10
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Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain, if no
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Who referred you?
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Anything else you would like to share?
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