Health Consultation

Name:

Address:  

City: State:   Zip:

Email:    Phone:

Age:     Date of birth:    Height: 

Current weight:   Weight one year ago   Ideal weight:

Ancestry:   Blood type:

Relationship status:   Children:

Occupation:   Stress levels (1-10, low to high): 1 2 3 4 5 6 7 8 9 10

How often do you exercise:   Preferred exercise activities:

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Describe your typical diet:

Breakfast:


Lunch:


Dinner:


Snacks:


Beverages:


Supplements or medications:


How often to you cook at home? 

How often do you eat out? 

Do you have any cravings for or addictions to sugar, caffeine, tobacco, or alcohol?

If yes, please list:

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What is your primary health concern?


What has been done in the past to work on this health condition?


What has proven effective?


What obstacles, challenges and struggles do you face regarding diet and lifestyle?


Where would you like your health to be 4-6 months from now?


Would individualized support help you attain your goals?   Yes     No

What do you hope to get out of this consultation session?