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Consultation Information
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Name
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Preferred Method of Contact
*
Email
Phone
Text
Age / Birthday
Your answer
Main Complaint(s)
*
Your answer
Short Term Goal?
Your answer
Long Term Goal?
Your answer
How is/was the health of your mother?
Excellent
Very good
Good
Fair
Poor
If "Fair" or "Poor" - What are/were her health challenges?
Your answer
How is/was the health of your father?
Excellent
Very good
Good
Fair
Poor
If "Fair" or "Poor" - What are/were his health challenges?
Your answer
At what point in your life did you feel your best, and why?
Your answer
Any Surgeries / Hospitalizations?
Your answer
Any supplements or medications?
Your answer
Are you working with anyone now for your health (doctors, alternative medicine etc.)?
Your answer
Do you Exercise?
Yes, all the time
Yes, sometimes
Rarely
Not at all
Other:
Clear selection
Foods you eat on a regular basis for breakfast?
Your answer
Foods you eat on a regular basis for lunch?
Your answer
Foods you eat on a regular basis for dinner?
Your answer
Foods you eat on a regular basis for snacks?
Your answer
How often do you cook or eat at home
90% of the time - I love to cook
75% of the time
50% of the time - I love to go out
Hardly ever... Why do you think restaurants were invented?
Other:
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If you don't eat at home most of the time, where do you get your food? (Check all that apply)
Restaurants
Fast Food
Take-out
Prepared Foods from market
Other
Do you have any cravings / addictions? (check all that apply)
Sugar
Coffee
Cigarettes
Alcohol
Other
Anything else you'd like me to know?
Your answer
Today's Date
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