Name
*
Nombre
Apellidos
Age
*
Date of Birth
*
Email
*
Mobile Phone
País
(###)
###
####
Relationship Status
*
Where do you live?
*
Any children?
*
Any pets?
*
Occupation
*
What are your main health concerns?
*
Any other concerns and/or goals?
At what point in your life did you feel your best?
Any current or previous serious illnesses, hospitalizations, or injuries?
How is your sleep?
How many hours do you sleep per night?
Do you wake up during the night? If so, why?
Any pain, stiffness, or swelling?
Any constipation, diarrhea, or gas?
Any allergies or sensitivities?
Are your periods regular?
How many days is your flow?
How frequent?
Are your periods painful or symptomatic? If so, please explain
Have you reached or are you approaching menopause? If so, please explain
List all supplements or medications
Are you involved with any healers, helpers, or therapies?
What role do sports and exercise play in your life?
Will your family and friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?
What percentage of your food is home-cooked?
Where does your non-home-cooked food come from?
Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?
What is the most important thing you should change about your diet to improve your health?
Is there anything else you would like to share?
