List all three if you know them.


What is your ideal weight? Why?


Names, ages, do they live with you?


Do you have any pets? Describe the role they play in your life.


What do you do and how many hours per week do you work?


Is your lifestyle sedentary or active? Explain for both work and home.


Describe your computer/tablet/phone and television viewing habits. What do you watch and how often?


Rank you level of stress on a scale of 1-10. What are the biggest stressors in your life? How does stress affect you?


How and when do you feel connected to something greater than yourself?


What are your main health concerns?


Please describe your sleeping habits.


Do you have any other concerns and/or goals?


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


Do you have any serious illnesses, chronic disorders or injuries?


How happy are you? Explain.


Please list the medications and supplements that you take.


How often have you used antibiotics in your life? Why?


Are you involved with any healers, therapists or other advisors? Please explain.


How often do you exercise? Is your current routine (or lack thereof) enough to sustain your desired level of fitness?


Are your periods regular? What are your cyclical symptoms? What birth control do you prefer?


What was your diet like as a child. Please list specific foods for breakfast, lunch, dinner, snacks and liquids.


What foods do you eat these days? Please be specific for breakfast, lunch, dinner, snacks and liquids.


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?


Do you crave sugar, coffee, cigarettes, alcohol or fast food? What and when?


Will family, friends and co-workers be supportive of any diet changes you choose to make?


What is the most important thing you know you should do to improve your health?


What motivates you? What do you procrastinate/avoid?


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.


Is there anything else you'd like to share?