New Client Health History Form

Name *

First

Last

Email *

Phone Number (Primary)

Age

Height

Current Weight

Where do you live?

Occupation

What are your top 3 health concerns?

Other goals you're hoping to achieve or concerns you're hoping to address with this investment?

Any serious illnesses, hospitalizations or injuries?

Are you currently taking any daily supplements or medications?

Are you currently working with any other health professionals, energy healers or therapists to achieve your goals? If yes, please list them and how they are helping you.

How would you describe your current relationship with food?

Tell me about the role exercise has in your life.

On a scale of 1-10 (10 being the highest), how stressed are you currently? Please provide some explanation for why you chose that number.

Describe a typical breakfast:

Describe a typical lunch:

Describe a typical dinner:

Describe your current snacking habits:

Do you currently follow a specific diet and if so, if that working for you? If not, how would do you have an idea of which type of diet you'd like to follow?

Describe your current sleep in terms of consistency, quantity, and quality.

Are you a smoker?

How many alcoholic beverages per week do you consume?

In your opinion, what is the most important change you can make to accomplish your goals?

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