Name

Email address

Age

Date of birth

Current weight

Weight one year ago

If so, what?

Children

Occupation

Please list your main health concerns

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

How is the health of your mother?

What is your ancestry?

Do you have any pain, stiffness, or swelling?

What role do sports and excercise play in your life?

Will your friends/family support your desire to make food/lifestyle changes?

Do you cook?

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

Address

Best phone number to reach you at

Height

Place of birth

Weight six months ago

Would you like your weight to be different?

Relationship status

Pets

Hours of work per week

Other concerns or goals

Any serious illneses/hospitalizations/injuries?

How is the health of your father?

Do you sleep well?

Do you take any supplements or medicaiton? Please list:

What’s your food like these days?

What percentage of your food is home cooked?

Where do you get the rest from?

The most important thing I should change about my diet to improve my health is: