Your Name (required) Your Email (required) Phone Age Height Birth date Current Weight - 6mo ago - 1 year ago List all three if you know them. Ideal weight What is your ideal weight? Why? Relationship status ---MarriedSingleLive-in PartnerIn a Relationship Children Names, ages, do they live with you? Animals Do you have any pets? Describe the role they play in your life. Occupation What do you do and how many hours per week do you work? Lifestyle Is your lifestyle sedentary or active? Explain for both work and home. Media consumption Describe your computer/tablet/phone and television viewing habits. What do you watch and how often? Stress Rank you level of stress on a scale of 1-10. What are the biggest stressors in your life? How does stress affect you? Spirituality How and when do you feel connected to something greater than yourself? Health Concerns What are your main health concerns? Sleep Please describe your sleeping habits. Other Do you have any other concerns and/or goals? Best Life At what point in your life did you feel your best? Why? Disorders Do you have any serious illnesses, chronic disorders or injuries? Happiness How happy are you? Explain. Medication Please list the medications and supplements that you take. Antibiotics How often have you used antibiotics in your life? Why? Therapy Are you involved with any healers, therapists or other advisors? Please explain. Exercise How often do you exercise? Is your current routine (or lack thereof) enough to sustain your desired level of fitness? Women's Health Are your periods regular? What are your cyclical symptoms? What birth control do you prefer? Childhood diet What was your diet like as a child. Please list specific foods for breakfast, lunch, dinner, snacks and liquids. Current Diet What foods do you eat these days? Please be specific for breakfast, lunch, dinner, snacks and liquids. Food priorities Do you prioritize quantity, quality, taste, convenience, ingredients, food source and/or certain diet preferences? Do you manage calories, carbs, fat and/or protein ratios? Cravings Do you crave sugar, coffee, cigarettes, alcohol or fast food? What and when? Support Will family, friends and co-workers be supportive of any diet changes you choose to make? #1 What is the most important thing you know you should do to improve your health? Motivates What motivates you? What do you procrastinate/avoid? Personality Do you prefer professionals who tell you what to do? Or do you prefer lots of information and options so you can do your own research? Please comment on your personality style and preferences to health recommendations. Anything else? Is there anything else you'd like to share?