Intake Form

Please fill out the form below to the best of your ability. All of your information will remain confidential between me and you.

Name(required)

Email(required)

Phone

Age

Birthdate

Place of Birth

Relationship Status? (Married, Single…)

Where Do You Live?

Children

Pets

Occupation

Hours of Work Per Week

Please list your main health concerns:(required)

Other concerns and/or goals?

At what point in your life did you feel best?:(required)

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:

Do you take any supplements or medications? Please list:(required)

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? (Breakfast, Lunch & Dinner, Snacks & Liquids)(required)

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?:

Do you cook?:(required)

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?:(required)

The most important thing I should do to improve my health is:(required)

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Additional comments or questions? Anything else you'd like to share?