Client Name:
Date:
Address:
City:
State:
Zip:
Email Address:
How often do you check email?
Telephone - Work:
Home:
Cell:
Age:
Height:
Date of Birth:
Place of Birth:
Current weight:
Weight six months ago?
One year ago?
Relationship status:
Children?
Occupation:
How many hours a week do you work?
To urinate:
What time do you generally get up in the morning?
What blood type are you?
What is your ancestry?
Women:
Do you take any supplements or medications? If so, which?
Are there any healers, helpers or therapies with which you are involved? Please list:
What role does exercise play in your life ?
Do you drink coffee, smoke cigarettes, or have any major addictions?
What percentage of your food is home cooked ?
% Where do you get the rest from?
Serious illness / hospitalizations / injury
How is the health of your mother?
How is the health of your father?
What is your chief concern?
Other concerns?
What foods did you eat often as a child?
breakfast
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lunch
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dinner
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snacks
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liquids
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What about one year ago?
breakfast
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lunch
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dinner
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snacks
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liquids
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What's your food like these days?
breakfast
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lunch
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dinner
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snacks
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liquids
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