Name

First Name

Last Name

Date

YYYY

Birthdate

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Height

Weight

Occupation

Please describe any current health concerns, including the onset and occurrence of each.

How have you or how are you currently addressing these issues?

Do you have any allergies?

Are you currently taking any medications or supplements? If so, please list and include how long you've taken each.

Please list any health conditions of your parents and grandparents.

Do you recognize any relationship between your emotions, stress, and food?

How do you feel about your relationship to food?

Are you currently, or have you ever, been aware of any environmental or nutritional toxicity? If so, please explain.

Have you ever engaged in extreme dieting, bingeing or purging? If so, please explain.

Do you currently, or have you ever engaged in addictive behaviors, including alcohol, drugs, cigarettes or food? If so, please explain.

What were your eating habits like growing up?

What is your diet like currently? Please give a few examples of typical meals for breakfasts, lunches, dinners, snacks, and drinks.

How is your sleep? Do you have trouble falling or staying asleep? About how many hours of sleep do you typically get?

How are your moods in general? Do you experience depression or anxiety?

How are your energy levels?

Do you exercise? If so, please explain how often and type of activity.

For Women: How are your menstrual cycles? Do you experience pain, mood swings, do they occur monthly?

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