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PERSONAL INFORMATION



 

First Name

Last Name

  

Your Email

How often do you check email?

  

Phone: Home:

Work:

Mobile:

  

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?





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?







Women’s Health History

 

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:






WOMEN’S HEALTH

 

Are your periods regular?

How many days is your flow?

How frequent?

  

Are they 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


 

  



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 homecooked?

  

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 QUESTIONS:



    

1. When did you first started experiencing the symptoms?

2. What was/is your relationship with your mother?

3. What was/is your relationship with your father?

4. What would you say about your present relationship?

  

5. Are there any traumatic events in your life you remember?

  

6. What is your greatest desire?

  

7. What are your hobbies?

  

8. How do you spend your free time?

9. What are your regrets?

  

10. Do you hold grudges?

  

11. How do you percept change?

  



ADDITIONAL COMMENTS



    

Anything else you would like to share?

  



ARE YOU EXPERIENCING ANY OF THESE SYMPTOMS?



    

 

1.Frequent headaches2.Frequent migraine3.Fever4.Enlarged glands5.Sore throat (angina)6.Respiratory problems7.Allergies8.Getting sick on regular basis9.Ear itching10. Skin sensitivity11. Sinus infection12. Extensive perspiration13. All the time cold14. All the time hot15. Mood swings16. Gastrointestinal pain17. Irregular bowel movements18. Diarrhea19. IBS20. Urinating pain21. Problems with urinating22. Hip pain23. Pelvic pain24. Back pain25. Killer cramps26. Extensive menstrual bleeding