TODAYS DATE *

Name *

Email *

Phone

Age / Birthdate *

Current Weight *

Would you like your weight to be different? If so, what? *

Please list your main health concerns *

Other concerns and/or goals? *

At what point in your life did you feel best? *

Any serious illnesses/hospitalizations/injuries? *

How is your sleep? How many hours? *

Allergies or sensitivities? Please explain. *

Are your periods regular? How many days is your flow? Any pain?

Reached or approaching menopause? Please explain. *

Do you take any supplements or medications? Please list *

Any healers, helpers, or therapies with which you are involved? Please list. *

Do you exercise? If so how many days a week?How long? *

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? *

Do you crave sugar, coffee, cigarettes, or have any major addictions? *

The most important thing I should do to improve my health is... *

Anything else you would like to share?