Application (Copy) — CONSCIOUS LIVING

Email:

Age:

Date of Birth:

Place of Birth:

Current Weight:

Would you like your weight to be different?

Where do you live?

Any Children?

Any Pets?

Occupation?

How many hours a week do you work?

What are your main health concerns?

Any other concerns and/or goals?

Any current or previous serious illnesses, hospitalizations?

How is/was your mother's health?

How is/was your father's health?

What is your ancestry?

How is your sleep?

How many hours do you sleep per night?

Do you wake up during the night? If so, what time? Why?

Any pain, stiffness or swelling?

Any constipation, diarrhea, or gas?

Any allergies or sensitivities?

(If Applicable): Are your periods regular?

How many days?

Are your periods painful or symptomatic?

Have you reached or are you approaching menopause? If so, explain:

What is your birth control history?

(If Applicable): Do you experience yeast infections or urinary tract infections. If so, please explain:

List all supplements or medications:

Are you involved with any healers, helpers or therapies?

What role do sports and exercise play in your life?

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

Do you cook? If so, what percent of your food is home-cooked?

Where does your non-home-cooked food come from?

What foods did you eat often as a child for breakfast, lunch, dinner, snacks, drinks?

What foods do you typically eat these days for breakfast, lunch, dinner, snacks?

Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?

What's the most important thing you should change in your lifestyle to improve your health?

Is there anything else you would like to share?

Health History