Step 1 of 3 – General Info
Address Line 2
State / Province / Region
ZIP / Postal Code
Weight (Current Weight)
Weight (Six Months Ago)
Weight (One Year Ago)
What Would You Like Your Current Weight to Be?
I Sleep Well
I Wake Up At Night
Check All That Apply
How Many Hours Do You Sleep Per Night?
Married/In A Committed Relationship
Do You Have Children?
Hours You Work Per Week
List Your Main Health Concerns
Any Serious Illness/Hospitalizations/Injuries?
Describe Any Pain, Stiffness or Swelling
Are Your Periods Regular, Painful or Symptomatic? Please Explain
How Many Days Is Your Flow and How Frequent Are Your Periods
Please Describe Your Birth Control History
Do You Experience Yeast Infections Or Urinary Tract Infections? Please Explain.
Do You Experience Constipation/Diarrhea/Gas/Acid Reflux? Explain
Do You Have Any Allergies or Sensitivities? Explain
Describe At What Point In Your Life You Felt Best?
How Is The Health Of Your Mother?
How Is The Health Of Your Father?
What Is Your Ancestry?
What Blood Type Are You?
I Have No Idea
Please List Any Supplements or Medications You Take
List any Healers, Helpers, Pets Or Therapies With Which You Are Involved.
List What Role Sports And Exercise Play In Your Life
What Foods Did You Eat Often As A Child
List 3-4 types of foods or drinks that you ate as a child for each of the following meals.
What Foods Do You Eat These Days?
List 3-4 types of foods or drinks that you currently eat for each of the following meals.
What Percentage Of Your Food Is Home Cooked?
Please enter a value between
Where Do You Get Your Food From That Is NOT Home Cooked?
Will Family And/Or Friends Be Supportive Of Your Desire To Make Food And/Or Lifestyle Changes? Explain
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?
Is There Anything Else You Would Like To Share?