Client Name:      Date:

Street Address:

City:      State:      Zip code:

Email Address:      How often do you check your email?

Telephone Numbers:
Work: ext     Home:      Mobile:

Age:      Date of birth:      Place of birth:

Your Weight

Current weight:      Weight six months ago:     Weight one year ago:

Would you like your weight to be different? Yes    or   No    If yes, what weight?

Relationship Status:     Number of Children, if any:     Occupation:

How many hours per week do you work?     Do you sleep well? Yes   No

Do you wake up at night? Yes No   If yes, what time/s do you wake?

Do you wake at night to urinate?     What time do you wake in the morning?

Do you experience constipation or diarrhea? Yes  No 

If yes, Please explain:

What blood type are you?      What is your ancestry?

Women:

Are your periods regular? Yes No     How many days is your flow?

Frequency of periods:

Painful or symptomatic? Yes    No    If yes, Please explain:

Do you take any medications or health supplements? If so, please list:

Are there any other helpers, healers, pets or therapies with which you are involved? Please list:

What roll does exercise play in your life?

Do you drink coffee, smoke cigarettes, and/or have any addictions? Please list:

What percentage of your food is home cooked? %     Where do you get the rest from?

List history of serious illness / hospitalizations / injuries:

Mother's Health:

Father's Health:

What is your main health concern?

Other concerns?