Health History
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Email *
Name *
Email *
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?
A copy of your responses will be emailed to the address you provided.
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