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Current Client Revisit Form
New Female Client Health History
New Male Client Health History

Current Client Revisit Form - Please complete this prior to each scheduled session.

Personal Information

Name

First Name

Last Name

Email Address

Health Information

What positive changes have you noticed since your last session?

What are your main concerns at this time?

How is your sleep?

Any changes with weight?

Have you experienced any constipation, diarrhea or other digestive concerns?

How is your mood?

Food Information

Are you cooking more?

What foods do you crave?

What is your diet like these days?

Detail Breakfast, Lunch, Dinner, Snacks and Liquids

Additional Comments

Anything else you would like to share?

New Female Client Health History - Please complete this prior to our initial consultation.

Personal Information

Name

First Name

Last Name

Email Address

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Age

YYYY

Height

Place of Birth

Current Weight

Weight Six Months Ago

Weight One Year Ago

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

Social Information

Relationship Status

Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Children? Pets?

Occupation

Typical Hours/Days of Work Per Week

Health Information

Please list your main health concerns.

Do you have any other concerns/goals?

At what point in your life did you feel your best?

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 on average per night?

Do you wake up at night? Why?

Any pain, stiffness or swelling?

Constipation, Diarrhea, Gas or other Gastrointestinal Symptoms?

Allergies or sensitivities? Please detail.

Are your periods regular? How many days is your typical flow? How many days in your typical cycle?

Do you have any pain or other symptoms during your cycle?

Reached or approaching menopause? Please explain.

Birth control history.

Do you experience yeast infections or urinary tract infections?

Medical Information

Do you take any supplements or medications? Please list.

What role do sports and exercise play in your life?

Any healers, helpers or therapies with which you are involved? Please list.

Food Information

What foods did you eat often as a child?

Detail Breakfast, Lunch, Dinner, Snacks and Liquids.

What is your food like these days?

Detail Breakfast, Lunch, Dinner, Snacks and Liquids.

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

Do you cook?

What percentage of your food is home-cooked? What are typical things you cook?

Where do you get the rest from?

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

The most important thing I should do to improve my health is...

Additional Comments

Anything else you would like to share?

New Male Client Health History - Please complete this prior to our initial consultation.

Personal Information

Name

First Name

Last Name

Email Address

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Age

YYYY

Height

Place of Birth

Current Weight

Weight Six Months Ago

Weight One Year Ago

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

Social Information

Relationship Status

Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Children? Pets?

Relationship Status

Typical Hours/Days of Work Per Week

Health Information

Please list your main health concerns.

Do you have any other concerns/goals?

At what point in your life did you feel your best?

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 on average per night?

Do you wake up at night? Why?

Any pain, stiffness or swelling?

Constipation, Diarrhea, Gas or other Gastrointestinal Symptoms?

Allergies or sensitivities? Please detail.

Medical Information

Do you take any supplements or medications? Please list.

What role do sports and exercise play in your life?

Any healers, helpers or therapies with which you are involved? Please list.

Food Information

What foods did you eat often as a child?

Detail Breakfast, Lunch, Dinner, Snacks and Liquids.

What is your food like these days?

Detail Breakfast, Lunch, Dinner, Snacks and Liquids.

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

Do you cook?

What percentage of your food is home-cooked? What are typical things you cook?

Where do you get the rest from?

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

The most important thing I should do to improve my health is...

Additional Comments

Anything else you would like to share?