Consultation Information
This information is private and protected. I will not share this with anyone else.
Sign in to Google to save your progress. Learn more
Name *
Email Address *
Phone Number *
Preferred Method of Contact
Clear selection
Main Health Concern(s)
Other Concern(s) or Goals?
How is/was the health of your mother?
If "Fair" or "Poor" - What are/were her health challenges?
How is/was the health of your father?
If "Fair" or "Poor" - What are/were his health challenges?
At what point in your life did you feel your best, and why?
Have you had any serious illnesses / hospitalizations / injuries?
Any supplements or medications?
Any healers, helpers or therapies?
Exercise or Sports?
Foods that you eat regularly, both good and guilty pleasures?
How often do you cook or eat at home
Clear selection
If you don't eat at home most of the time, where do you get your food? (Check all that apply)
Do you have any cravings / addictions? (check all that apply)
Anything else you'd like me to know?
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy