Basic Information
Please fill out this form completely.  It is constructed so that all your information can be found at-a-glance and is used throughout our time working together.  Thank you and I look forward to working with you.  
Sign in to Google to save your progress. Learn more
Email *
Name *
Street  Address *
City & State: *
Zip Code *
What time zone are you in? *
Phone number *
Date of Birth *
MM
/
DD
/
YYYY
Age
Gender *
Height
Weight
Would you like your weight to be different?
Clear selection
If yes, what is your goal weight?
Occupation:
How many hours do you work per week?  If you are a stay at home parent, please count the work you do at home!
Clear selection
Referred by?
Hobbies/Activities
What are your health concerns? *
Did your health begin to deteriorate around a specific time or following an event/illness?
Clear selection
Please explain:
Are you currently under another practitioner’s care for any issues?
Clear selection
If yes, please explain:
What role does exercise play in your life?
Have you traveled out of the country in the last five years?
Clear selection
Where?
FOOD INTAKE
The following questions pertain to what you eat on a daily basis.  It's ok if your diet is not perfect or far from it!  Please be specific in your answers.  If you consume a smoothie, write what's in it.  If you eat out at a fast food restaurant, write what you eat there.   
What is a typical breakfast for you?  If none or just coffee, please write that down.  If you add anything to the coffee, please indicate that as well.  If you eat out half the time and in half the time, please indicate that along with the specifics of what you actually eat.  
If you do eat breakfast, what time?
What is a typical lunch for you?  
What time do you usually eat lunch?
What is a typical dinner for you?
What time do you usually eat dinner?
What snacks do you consume during the day?  If you'd like to indicate when you consume them, please do.  
When you do eat out, what food do you like to have?
I drink the following on a regular or semi-regular basis
My Blood Pressure usually runs:
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms