Please list your main health concerns.
Other concerns and/or goals?
At what point in your life did you feel best?
Any serious hospitalizations/illnesses/injuries?
Do you wake up at night? If yes, why?
Any pain, stiffness, or swelling? If yes, please explain.
Any constipation, diarrhea, or gas? If yes, please explain.
Any allergies or sensitivities? If yes, please explain.
Is your period painful or symptomatic? If yes, please explain.
Do you experience yeast infections or urinary tract infections? If yes, please explain.
Please explain your 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?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
The most important thing I should do to improve my health is:
How did you hear about me?
Additional comments or anything you'd like me to know:
Join the community today!