Posted by | August 26, 2013

    Name: Email address: Age:
    Height: Date of Birth: 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: Children: Pets:
    Occupation: Hours of work per week:
    Please list your main health concerns:
    At what point in your life did you feel best?
    Any serious illnesses/hospitalizations/injuries?
    Do you sleep well? How many hours? Do you wake up at night? Why?
    Any pain, stiffness or swelling?
    Constipation/Diarrhea/Gas? Please explain:
    Do you take any supplements or medications? Please list:
    What role do sports and exercise play in your life?
    What percentage of your food is home cooked? Do you cook?
    Do you crave sugar, coffee, cigarettes, or have any major addictions?
    The most important thing I should change about my diet to improve my health is:
    Anything else you want to share?

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