Intake FormThank you for signing up for a consultation. I look forward to working with you! Please complete the below intake form. Name * First Name Last Name Email * Phone Number * Country (###) ### #### Age * Current Weight * Please include llbs or kgs. Weight 6 Months Ago Weight 1 Year Ago Would you like your weight to be different? Yes No Social Relationship Status Location Any children? Any pets? Occupation How many hours do you work per week? General Health What are your main health concerns? Any other concerns or goals? At what point in your life did you feel your best? Any current or previous serious illnesses, hospitalizations, or injuries? How is/was your mother’s health? How is/was your father’s health? What is your ancestry? What is your blood type? How is your sleep? How many hours do you get? Do you wake up during the night? Yes No If so, why? Any pain, stiffness, or swelling? Any constipation, diarrhea, or gas? Any allergies or sensitivities? Medical Please list all supplements or medications. Are you involved with any healers, helpers, or therapies? What role do sports and exercise play in your life? Food Will your family and 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 does your non-home-cooked food come from? What foods did you eat often as a child? Breakfast Lunch Dinner Snacks Liquids What foods do you typically eat these days? Breakfast Lunch Dinner Snacks Liquids Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions? What is the most important thing you should change about your diet to improve your health? Is there anything else you would like to share? Thank you!
