First and Last Name:
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First Name
Last Name
Email:
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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?
Relationship status:
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Where do you currently live?
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Childern?
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Pets?
Occupation:
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Hours per week?
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Please list your main health concerns:
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Other concerns and/or goals?
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At what point in your life did you feel best?
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Any serious illnesses, injuries or hospitalizations?
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How is or was the health of your mother?
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How/is the health of your father?
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What is your ancestry?
How is your sleep?
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How many hours?
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Do you wake up at night?
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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?
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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?
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Reached or approaching menopause? Please explain:
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Birth control history:
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Do you experience yeast infections or urinary tract infections? Please explain:
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Do you take any supplements or medications? Please list:
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Any healers, helpers, 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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What foods did you eat often as a child? What was a typical breakfast, lunch and dinner?
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What is your food like these days? What is a typical breakfast, lunch and dinner?
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Will family and friends be supportive of your desire to make food and/or lifestyle changes?
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Do you cook?
What percentage of your food is home-cooked?
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Where do you get the rest of your food from?
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Do you crave sugar, coffee, cigarettes, or have any major addictions?
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The most important thing I should do to improve my health is:
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Anything else you would like to share?
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