Order Number Personal Information First Name * Email * Last Name * How often do you check email? * Home Phone Number * Work Phone Number * Mobile Number * 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? * Gender * Male Female Social Information Relationship status * Children * Occupation * Where do you currently live? * Pets * 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? * Any pain, stiffness, or swelling? * Constipation/Diarrhea/Gas? * Allergies or sensitivities? 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 * What is your food like these days? 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 * Additional Comments Anything else you would like to share? *
