Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Skype user name

Permanent address

Mailing address (if different)

Age, gender and place of birth

Current weight and height

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

Occupation

Relationship status

Do you have children? If so, what are their ages?

Do you sleep well? How many hours? What's your bedtime?

What makes you lose sleep?

Do you experience constipation or diarrhea?

How much water do you drink per day? What other beverages do you drink?

How often do you drink alcohol in a week? What do you typically drink, wine, beer, cocktails?

What blood type are you? What's your ancestry?

Women: Are your periods regular? Days of flow? Painful Symptoms?

Men: Do you experience any discomfort when urinating? Or any pain at all?

Please list any supplement or medications you take and reason

Current doctors, healers, or therapies. Please list.

Do you exercise or do any physical activity? What role does exercise play in your life?

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

Do you enjoy cooking? What percentage of your food is home cooked?

What are your favorite things to cook or meals to make?

What are your very favorite foods to eat?

What percentage of your food is homemade from scratch? Where do the rest of your meals come from?

Where do you shop for groceries? How often do you shop?

When is the last time you had a physical checkup?

What tests, if any were done during you physical checkup visit?

How would you describe your lifestyle?

Serious illness/ hospitalizations/ injuries?

What are your chief concerns about your health? What changes would you like to make?

What are your goals in health and life?

Mother's and father's health? Any serious illnesses?

What are your favorite ways to have fun? Hobbies?

Please list food allergies or any foods you dislike and why?

Are you generally happy? Do you experience any depression?

Please list what you ate for breakfast the last 3 days.

Please lest what you ate for lunch the last week.

Please list what you eat for dinner typically? What did you eat the past few night?

Emergency contact name and phone number