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Personal Information
Name
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Email
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Phone
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Date Of Birth
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Current Weight
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Age
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Weight 6 Months Ago
Place Of Birth
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One Year Ago
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Would you like your weight to be different?
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If so, what?
How is your Oral Health (Teeth, Gums, Tongue etc.,)
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Social Information
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Relationship Status
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Occupation
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Where do you currently live?
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Health Information
Please list your main health concerns *
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Other concerns and/or goals?
At what point in your life did you feel best?
Any serious illnesses/hospitalizations/injuries?
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How is/was the health of your mother?
What is your ancestry?
How is your sleep?
Do you wake up at night?
Any pain, stiffness, or swelling?
How is/was the health of your father?
What blood type are you?
How many hours?
Why?
Constipation/Diarrhoea/Gas?
Allergies or sensitivities? Please explain
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Women's Health
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Are your periods regular?
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How many days is your flow?
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How frequent?
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Painful or symptomatic? Please explain
Reached or approaching menopause? Please explain
Birth control history
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Do you experience yeast infections or urinary tract infections? Please explain
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Medical Information
Do you take any supplements or medications? Please list
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Any healers, helpers, or therapies with which you are involved? Please list
What role do sports and exercise play in your life?
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Food Information
What foods did you eat often as a child? Please list
What is your food like these days?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
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Do you cook ?
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No
Where do you get the rest from?
What percentage of your food is home-cooked?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is
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Additional Information
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