Please list your main health concerns
Other concerns and/or goals?
At what point in your life did you feel best?
Any serious illnesses / hospitalizations / injuries?
How is/was the health of your mother?
How is/was the health of your father?
Reached or approaching menopause? Please explain.
Birth control history
Do you take any supplements or medications? Please list.
Any healers, helpers or therapies with which you are involved? Please list.
What role do sports and exercise play in your life?
What foods did you eat often as a child?
What is your food like these days?
Additional Food Information
Do you cook?
What percentage of your food is home-cooked?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Anything else you would like to share?