Full Name

Email *

Phone *

Nickname

Facebook Link

Referred By

Getting To Know You

Current Age

Date of birth

Blood Type

Current Weight

Ideal Weight

Weight 6 months ago

Weight 1 year ago

Family Living Situation

Relationship Status

Married

Single

Separated

Divorced

Children?

Yes

No

Children Names and Ages

Occupation

Briefly describe symptoms, chosen treatment(s), and dates.

Health Concerns

What are your main health concerns? (Describe in detail, including the severity of the symptoms)

When did you first experience these concerns?

How have you dealt with these concerns in the past?

Doctors

Self-Care

Have you experienced any successes with these approaches?

How do you feel facing this problem?

What health practitioners are you currently seeing?

How often do you take antibiotics as a child/teen/adult?

List al the vitamins, minerals, herbs, and nutritional supplements you’re taking now:

Have any other family member(s) had similar problems (describe)?

How are/were your menses? Do/did you have PMS? Painful periods? If so, please explain:

Have you experienced any yeast infections or urinary tract infections? Are they regular?

Have you/do you still take birth control pills? If so, please list length of time and type.

Have you had any problems with conception or pregnancy?

Are you taking any hormone replacement therapy or hormonal supportive herbs? If so, please list:

Lifestyle History

Are you currently on a special diet?

Diabetic

Dairy Restricted or Dairy-‐Free

Wheat-‐Free

Vegetarian

Vegan

80/20

Raw

Paleo (fish, grass-‐fed pasture raise meats, eggs, vegetables, fruit, fungi, roots, and nuts: no grains,legumes,dairy products, potatoes, refined salt, refined sugar, or processed oils)

Other (please describe)

Is there anything else I should know about your current diet, history, or relationship to food?

Have you had periods of eating junk food, binge eating, or dieting? List any known diet that you have been on for a significant amount of time:

How are your moods in general? Do you experience more than you would like of anxiety? Depression? Anger?

How do you handle stress?

On a scale of 1-‐‐10, one being the worst and 10 being the best, describe your usual level of energy.

Describe your sleep patterns. Can you get sleep easily? Can you stay asleep? How many hours do you average a night?

What do you do for recreation?

What do you do for physical activity/exercise? How many times per week?

At what point in your life did you feel best? Why?

Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain if no:

Who in your family, circle of friends, or on your health care team will be most supportive of you making dietary changes?

What are your health goals and aspirations?

Anything else you want to share?