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Personal Information
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Name:
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Address:
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Email:
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How often do you check email?
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Home Phone:
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Work Phone:
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Cell Phone:
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Age:
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Height:
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Birthdate:
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Place of Birth:
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Current Weight:
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Weight six months ago:
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Weight one year ago:
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Would you like your weight to be different?
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If so, what?
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Social Information
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Relationship status:
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Do you have children?
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Do you have pets?
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Occupation:
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Hours of work per week:
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Health Information
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Please list your main health concerns:
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Other concerns or goals?
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At what point in your life did you feel best?
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Any serious illness, hospitalizations or injuries?
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How is the health of your mother?
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How is the health of your father?
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What is your ancestry?
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What blood type are you?
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Do you sleep well?
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Do you wake up at night?
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If so, why?
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Any pain, stiffness or swelling?
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Constipation, diarrhea or gas?
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Allergies or sensitivities?
Please explain:
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Are your periods regular?
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How many days is your flow?
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How frequent?
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Painful or symptomatic?
Please explain:
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Reaching or approaching Menopause?
Please explain:
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Birth control history:
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Vaginal infections or reproductive concerns?
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Medical Information
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Do you take any supplements or medications?
Please List:
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Are there any healers, helpers, pets or therapies with which you are involved?
Please List:
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What role do sports and exercise play in your life?
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Food Information
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What foods did you eat often as a child? |
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Breakfast:
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Lunch:
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Dinner:
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Snacks:
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Liquids:
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What’s your food like these days? |
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Breakfast:
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Lunch:
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Dinner:
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Snacks:
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Liquids:
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Will family and friends be supportive of your desire to make food and lifestyle changes?
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Do you cook?
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What percentage of your food is home cooked?
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What percentage is not?
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Where do you get the rest from?
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Do you crave sugar, coffee, cigarettes, or have any major addictions?
Please explain:
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The most important thing I should change about my diet to improve my health is:
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Additional Comments
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Anything else you would like to share?
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