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First Name*
Last Name*
Email*
How often do you check e-mail:
Home Phone:
Work Phone:
Mobile Phone:
Age:
Height:
Birthdate:
'
Month
Day
Year
Place of Birth:
Current weight:
Weight six months ago:
One year ago:
Would You Like Your Weight To Be Different?:
If so, what?:
Social Information
'
'
Relationship status:
Where do you currently live?:
Children:
Pets:
Occupation:
Hours of work per week:
Health Information
'
'
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:
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:
Medical Information
'
'
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?:
Food Information / What Foods Did You Eat Often As A Child?
'
'
'
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
Will Family And/Or Friends Be Supportive Of Your Desire To Make Food And/Or Lifestyle Changes?:
Do you 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:
What is your food like these days?
'
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
Additional Comments
'
'
Anything Else You Would Like To Share?:
Print your name
submit
submit
thanks
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Personal Information

Women's

Health History

Birthdate:

Social Information

Health Information

Medical Information

Food Information

Additional Comments

What foods did you eat often as a child?

What is your food like these days?

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