Name
*
First Name
Last Name
Email Address
*
Phone
(###)
###
####
Age
Birthdate, time + location
Height
Current Weight
Would you like your weight to be different? If so, what?
Relationship status:
Children:
Where do you currently live?
Occupation:
Please list your main health concerns:
Other concerns and/or goals?
At what point in your life did you feel best?
Any serious illness/hospitalizations/injuries?
How is/was the health of your mother?
How is/was the health of your father?
How is your sleep? How many hours do you get on average? Do you wake up at night? Why?
Any pain, stiffness, or swelling?
Constipation/Diarrhea/Gas?
Allergies or sensitivities?
What role do sports and exercise play in your life?
What role does stress play in your life?
Do you take any supplements or medications? Please list.
Do you work with any healers, helpers, or therapies? Please list.
What foods did you eat often as a child?
Please list a few examples of typical breakfast, lunch, dinner, and snacks.
What foods do you eat now?
Please list a few examples of typical breakfast, lunch, dinner, and snacks.
Do you cook? What percentage of your food is home cooked?
Where do you get the rest of your food from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
Are your periods regular? How many days is your flow? How frequent? Painful cramps or other symptoms?
Birth control history
Reached or approaching menopause?
Do you feel connected to your intuition? How do you connect to yourself?
Please share your spiritual practices, if any
Which of the following are you interested in incorporating in our program?
Anything else you would like to share?
