Client History

First Name

Last Name

How often do you check messages?

Primary Phone

Secondary Phone

May I text you?

Age

Height

Birthdate

Place of Birth

Current weight

Weight six months ago

One year ago

Would you like your weight to be different?

If so, what?

Relationship status

Where do you currently live?

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/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

What blood type are you?

How is your sleep?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain:

- Please include relevant data -

Are your periods regular?

periods

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:

Do you take any supplements or medications? Please list:

Any healers, helpers, or therapies with which you are involved? Please list

What role do sports and exercise play in your life?

What foods did you eat often as a child?

Breakfast Child

Lunch Child

Dinner Child

Snacks Child

Liquids Child

What is your food like these days?

Breakfast Now

Lunch Now

Dinner Now

Snacks Now

Liquids Now

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

Support

Do you cook?

Cook?

What percentage of your food is home-cooked?

Where do you get the rest from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

The most important thing I should do to improve my health is:

Anything else you would like to share?

Stress Management

Rebound After Injury

Sustainable Weight Loss

Smoking Cessation

Focus

Sleep

Nutrition

Client History

Ready to Start?

Focus

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