Client Name:    Date:

Address:    City:    State:    Zip:

Email Address:    How often do you check email?    

Telephone - Work:    Home:    Cell:

Age:    Height:    Date of Birth:    Place of Birth:

 

Current weight:    Weight six months ago?    One year ago?

 

Relationship status:    Children?    

Occupation:    How many hours a week do you work?

 

To urinate:    What time do you generally get up in the morning?    

 

What blood type are you?    What is your ancestry?

Women:
 

Do you take any vitamins/medications? If so, which?


Are there any other healers, helpers, pets, or therapies with which you are involved? Please list


What role does exercise play in your life ?

Do you drink coffee, smoke cigarettes, or have any major addictions?

What percentage of your food is home cooked ? %   Where do you get the rest from?

Serious illness / hospitalizations / injury


How is the health of your mother?

How is the health of your father?

What is your main health concern?


Other concerns?


 

What foods did you eat often as a child?

 

What about one year ago?

 

What's your food like these days?