Your first step is simply filling out the form below. Please allow 8-10 minutes to complete your health history. First Name *Last Name *Email Address *How often do you check your email?Phone Number *Work NumberMobile NumberGender *MaleFemaleAge *Height *Birthdate *Place of Birth *Current Weight:Weight 6 Months Ago:Weight 1 Year Ago:Would you like your weight to be different? If so, what?Summer AddressStreet Address *City *State/Province *ZIP / Postal Code *Winter AddressStreet Address *City *State/Province *ZIP / Postal Code *Relationship Status *SingleMarriedIn a RelationshipDivorcedSeparatedWidowedNumber of Children *Number of Pets *Occupation *Hours of Work per Week *HEALTH INFORMATIONPlease List Your Main Health Concerns: *Other Concerns and/or GoalsAt what point in life did you feel your best? *Any serious illnesses/hospitalizations/injuries? *How is/was the health of your mother? *How is/was the health of your father? *What is your ancestry? *What is your blood type? *How is your sleep? *How many hours a night? *If so, why?Any pain, stiffness, or swelling?Constipation/Diarrhea/Gas?Allergies or sensitivities? Please explain:WOMENS HEALTHAre your periods regular? *YesNoN/AHow frequent?How many days is your flow?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 INFORMATIONDo 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? BreakfastLunchDinnerSnacksLiquids What is your food like these days?Current BreakfastCurrent LunchCurrent DinnerCurrent SnacksCurrent LiquidsWill family and/or friends be supportive of your desire to make food and/or lifestyle changes? *Do you cook?YesNoWhat 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:Anything else you would like to share?Best Way to Contact You: *EmailPhoneBest Time to Contact You: *MorningsAfternoonsEveningsSUBMITPlease do not fill in this field.