Name:  

Address:  

Email Address:  

How often do you
check your email?  

Telephone:
Work:     Home:    Mobile:  

Age:       Height:  

Date of Birth:    Place of Birth:  

Current Weight:    Six Months Ago:    One Year Ago:  

Would you like your
weight to be different?  Yes  No      If so, what?  

Relationship Status:    Children:  

Occupation:    Hours of work per week:  

Do you sleep well?  Yes  No

Do you wake up nights?  Yes  No      What times?  

To urinate:  Yes  No

What time do you generally get up in the morning?  

Constipation/Diarrhea?  

Do you know what blood type you are?  

Women:

Are your periods regular?  Yes  No

How many days is your flow?        How frequent?  

Painful or syptomatic?  Yes  No    Please explain:  

Everyone:

Do you take any vitamins
or medications?  If so, which?  

Are there any healers, helpers, or therapies
with which you are involved?  

What role does exercise
play in your life?  

Do drink coffee,
smoke cigarettes or
have any major addictions?

Coffee Drinker
Smoker
Major Addictions    If so, to what?  

What percentage of food is cooked at home?  

Where do you get the rest from?  

Serious illness /
hospitalizations or injuries?  

What is your chief concern?  

Other concerns?  

How is the health of your mother?  

How is the health of your father?  

What foods did you eat often as a child?

Breakfast:  

Lunch:  

Dinner:  

Snacks:  

Liquids:  

What about a year ago?

Breakfast:  

Lunch:  

Dinner:  

Snacks:  

Liquids:  

What do you eat now?

Breakfast:  

Lunch:  

Dinner:  

Snacks:  

Liquids: