First Name

Last Name

Phone Number

Email Address

Age

Height

Date of Birth

Place of Birth

Current Weight

Weight One Year Ago

Would you like your weight to be different? If so, how?

Relationship Status

Current Residence

Any children?

Any pets?

Occupation

How many hours per week do you work?

What are your main health concerns?

Any other concerns and/or goals?

At what point in your life did you feel your best?

Any current or previous 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?

Rate your sleep on a scale of 1-10 (10 being the best)

How many hours do you sleep per night?

What are your challenges with sleep? What allows you to get your best sleep?

Rate your nutrition on a scale of 1-10 (10 being the best)

What are your challenges with food? What allows you to eat your healthiest?

Rate your movement on a scale of 1-10 (10 being the best)

What is your duration of movement per day?

What role does physical activity play in your life? What activities do you enjoy?

Rate your emotional health on a scale of 1-10 (10 being the best)

What are your challenges with emotional health? What activities support your emotional health?

List all supplements and medications you are currently taking and have taken in the last year.

Any constipation, diarrhea, or gas?

Any allergies or sensitivities?

Will your family and friends be supportive of your desire to make lifestyle changes?

What food did you eat often as a child? Please describe breakfast, lunch, dinner, snacks and beverages.

What food do you typically eat currently? Please describe breakfast, lunch, dinner, snacks and beverages.

Please list any cravings here (ie. sugar, coffee, cigarettes).

What lifestyle change is most important to you right now to take the next step in improving your health?

Is there anything else you would like to share?