Please write or print clearly. All of your information will remain confidential between you and me. PERSONAL INFORMATION First Name: Last Name: Email: How often do you check email?: Best number to reach you: Age: Height: 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?: Grandchildren: Occupation: Hours of work per week: What is your retirement plan?: HEALTH INFORMATION Please list your main health concerns: Other concerns and/or goals?: At what point in your life did you feel 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 blood type are you?: 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: 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 does exercise play in your : life?: What is your energy like?: Do you still feel independent? Please explain: Are you part of a community? Please explain: FOOD INFORMATION What foods did you eat often as a child? Breakfast: Lunch: Dinner: Snacks: Liquids: What is your food like these days? Breakfast: Lunch: Dinner: Snacks: Liquids: 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?: