Name
Full Address
Email Address
How often do you check your email? Daily A few times a week Rarely Telephone – Work
Telephone – Home
Telephone – Cell
Age
Height (feet & inches)
Current Weight
Weight six months ago
Weight one year ago
Would you like your weight to be different? If so, what is your goal weight?
Date of Birth
Place of Birth
Occupation
Hours per Week
Gender Female Male Other / Prefer not to say Are your periods regular? Yes No Not applicable (menopause) Menopause status Not yet Perimenopause Post-menopause Not applicable How many days is your flow?
How frequent are your cycles? (days between periods)
Are your periods painful or symptomatic? Please explain any symptoms or concerns
Birth control history
Vaginal infections or reproductive concerns?
Please list your major health concerns
When was the last time you felt really vibrant and well?
Other current major life concerns
If you could wave a magic wand and change two things, what would they be?
Any serious illness, hospitalizations, injuries, or surgeries?
How is the health of your mother? (or cause of death)
How is the health of your father? (or cause of death)
What is your ancestry?
What is your blood type?
How many hours do you usually sleep?
If yes, please explain (e.g. bathroom, pain, restless mind, etc.)
Any ongoing sources of inflammation (eczema, post nasal drip, congestion, headaches, achy joints)?
Do you struggle with constipation, diarrhea, gas, distension, belching, or bloating? Which?
Please explain your digestion in detail
List ALL supplements or medications you take (and frequency)
Antibiotic use history (how often, for what, how long?)
Any remarkable exposure to toxins (home, work, hobbies, pesticides, heavy metals, etc.)?
General status of your dental / oral health
Any troubling dental work, dental/oral infections, root canals, dentures, etc.?
How many silver / mercury fillings do you have?
On a scale of 1–10, how would you rate your general energy level?
What do you attribute this energy level to?
Any healers, helpers, pets, or therapies you are involved with?
What are your primary hobbies?
What role do sports and exercise play in your life?
What do you do to relax? How often?
What was your general health and well‑being as a child?
What foods did you eat as a child? (Breakfast, lunch, dinner, snacks, liquids)
What is your food like these days? (Breakfast, lunch, dinner, snacks, liquids)
Do you have any food allergies or sensitivities?
What percentage of your food is home cooked?
What percentage is not home cooked?
Where do you get the rest from? (restaurants, takeaway, etc.)
If you have a general philosophy or mindset when choosing foods, please describe
Do you crave sugar, carbs, alcohol, coffee, cigarettes, or other foods? Any addictions?
Anything else you would like to share?
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