Name
*
First Name
Last Name
Address
*
Email address
*
How often do you check email?
Telephone
*
Age
Date of Birth
MM
DD
YYYY
Place of Birth
Height (cm)
Current weight (kg)
Weight six months ago (kg)
Weight one year ago (kg)
Would you like your weight to be different?
If so, what? (kg)
Relationship status
Children
Pets
Occupation
Hours of work per week
Please list your main health concerns
Other concerns and/or goals
At what point in your life did you feel best?
Any serious illnesses/hospitalisations/injuries
How is/was the health of your mother?
How is/was the health of your father?
What blood type are you?
Do you sleep well?
How many hours?
Do you wake up at night? If yes, why?
Any pain, stiffness or swelling?
Please answer the following 6 questions if appropriate for you: Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic? Please explain:
Reached or approaching menopause? Please explain:
Birth control history
Do you experience yeast infections or urinary tract infections? Please explain:
Constipation/diarrhea/gas? Please explain:
Allergies or sensitivities? Please explain:
Do you take any supplements or medications? Please list:
Are you seeing other therapists, helpers, healers? Please list:
What role does sport play in your life? What and how often?
What foods did you often eat as a child? mention breakfast, lunch, dinner, snacks, drinks
What's your food like these days? breakfast, lunch, dinner, snacks, drinks
Will family and/or friends be supportive or you making food and/or lifestyle changes?
What percentage of your food is home cooked?
Do you cook?
Where do you get the rest from?Do you
Do you crave sugar, coffee, cigarettes or have any major addictions?
Do you drink alcohol?
How much per week?
The most important thing I should change about my diet to improve my health is:
Anything else you want to share?