Personal information

Your First Name *

Your Last Name *

Your Email *

How often do you check your phone (eg for email etc)? *

Phone Mobile: *

WApp: *

Age: *

Date of Birth: *

Place of Birth: *

Current place you live: *

Current Weight: *

Height: *

If you have a current weight target, please specify: *

Social information

Relationship status: *

Children: *

Pets: *

Occupation: *

Hours of work per week: *

Health information

Please list your main health concerns: *

Any other concerns and/or goals? *

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

Any serious illnesses/ hospitalisations/ injuries? *

How is/was the health of your mother? *

How is/was the health of your father? *

What is your ancestry? *

Which blood type are you? *

How is your sleep (/10)? *

How many hours? *

If you wake up at night; for what reason? *

How is your energy (/10)? *

Any chest pain or shortness of breath? *

Any headaches? *

Any problems with your eyesight, smell, taste or hearing? *

Any pain, stiffness, or swelling? *

Any reflux? *

Constipation/ diarrhea/ gas? *

How is your flow when you go to the bathroom? *

Allergies or sensitivities? Please explain: *

For women

Are your periods regular?

How many days is your flow?

How frequent?

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 you’re experiencing? Please list: *

What role do sports and exercise play in your life? Please give details of any exercise you do: *

Food information

Which foods did you eat often as a child?

Breakfast: *

Lunch: *

Dinner: *

Snacks: *

Liquids: *

Please summarise your meals etc from yesterday:

Breakfast: *

Lunch: *

Dinner: *

Snacks: *

Liquids: *

Are your family and/or friends supportive of your desire to help your health incl any lifestyle changes? *

Do you prepare your own food, if yes - what percentage of your food is home-prepared? *

Where do you source the rest of your food from? *

Do you crave sugar, coffee, cigarettes, alcohol etc or have any major addictions? *

How much plain filtered water do you drink each day? *

The most important thing I need to do to improve my health is: *

Additional comments

Anything else you’d like to share?

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