Free Consultation Form

To schedule your FREE THIRTY MINUTE INITIAL CONSULTATION, please complete & submit the form below.
I look forward to meeting with you.

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PERSONAL INFORMATION

First Name

Last Name

How often do you check email?

Home Phone

Work Phone

Mobile Phone

Age

Birthdate

Place of Birth

Current Weight

Weight six months ago

One year ago

Would you like your weight to be different?

If so what?

SOCIAL INFORMATION

Relationship Status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week

HEALTH INFORMATION

Please list your main health concerns

Other concerns or goals?

At what point in your life did you feel best?

Any serious illness/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

How is your sleep?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain:

WOMEN'S HEALTH AREA

Are your periods regular?

How many days is your flow?

How frequent?

Painful or symptomatic? Please explain:

Reached or approaching menopause? Please explain:

Birth control history:

Do you experience yeast infections or urinary tract infections? Please explain:

MEDICAL INFORMATION

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?

FOOD INFORMATION

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?

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:

ADDITIONAL COMMENTS

Anything else you would like to share?

If you are human and are seeing this field please type HUMAN in the box below. *