Name
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First Name
Last Name
Email
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Phone
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(###)
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What is your preferred method of communication?
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Age
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Birthdate
Place of birth
Current Location
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Height
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Current weight
Weight six months ago
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Weight one year ago
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Would you like your weight to be different?
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If so, what would you like your weight to be?
Relationship status
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Children?
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Any pets?
Occupation
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How many hours do you work each week?
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Please list your main health concerns:
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Other concerns or goals?
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At what point in your life did you feel your best?
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Any serious illnesses, injuries or hospitalizations?
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How is or was the health of your mother?
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How/is the health of your father?
What is your ancestry?
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Blood type?
How is your sleep?
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How many hours?
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Do you wake up at night?
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Why?
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Any pain, stiffness or swelling?
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Constipation, diarrhea or gas?
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Allergies or sensitivities?
Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic?
Reached or approaching menopause? Please explain
Birth control history
Do you experience yeast infections or urinary tract infections? Please explain
Do you take any supplements or medications? Please list:
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Any healers, helpers, or therapies with which you are involved? Please list:
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What role do sports and exercise play in your life?
At what point in your life were you feeling your best?
Why, what was different?
What foods did you eat often as a child? What was a typical breakfast, lunch and dinner?
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What is your food like these days? What is a typical breakfast, lunch and dinner?
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Will family and friends be supportive of your desire to make food and/or lifestyle changes?
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Do you cook?
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What percentage of your food is home-cooked?
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Where do you get the rest of your food from?
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Do you crave sugar, coffee, cigarettes, or have any major addictions?
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How many alcoholic drinks do you consume per week?
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Do you currently use Cannabis and/or CBD?
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Are you open to or interested in learning about cannabis &/or CBD?
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The most important thing I should do to improve my health is:
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Anything else you would like to share?
