Client name   Date 

Address  City  

State   Zip  

Phone - work    home   email

Age . Date of Birth   Place of Birth

Current weight Weight six months ago? One year ago?

Would you like your weight to be different?   If so, what?

Relationship status Children? Occupation Blood Type

How many hours a week do you work?

Do you sleep well? Do you wake up at nights? What time(s)?

What time do you generally get up in the morning? Constipation / Diarrhea

Women: Are your periods regular? How many days is your flow? How frequent .

Painful or symptomatic?  Please explain

Do you take any vitamins / medications? If so, which?

. Are there any other healers, helpers, pets, or therapies with which you are involved? Please list

What role does exercise play in your life ?

Do you drink coffee, smoke cigarettes, or have any major addictions?

What percentage of your food is home cooked ? %   Where do you get the rest from?

How is the health of your father?

How is the health of your mother?

Serious illness / hospitalizations / injury
 

What is your chief health concern?

Other concerns?

What foods did you eat often as a child ?

          What about a year ago ?

 WhatÐs your food like these days ?