Let’s Start Your Health Journey!

Your First Name *

Your Last Name *

Your Email: *

Your Occupation *

How many hours do you work per week on average? *

Relationship Status *

Do you have children/grandchildren? *

Do you have pets? *

Your Age: *

Your Birthday (Month and Day) *

Your Height: *

Your Weight: *

What time do you typically go to sleep? *

What time do you usually wake up in the morning? *

What is your typical breakfast? *

What is your typical lunch? *

What is your typical dinner? *

What do you like to snack on in between meals? *

Do you smoke? *

Do you drink alcohol? *

Do you drink coffee or caffeinated tea? *

Do you drink soft drinks? *

How often do you exercise? *

I enjoy the following types of Exercise: (check all that apply) *

How do you handle stress? (check all that apply) *

What do you believe are the main causes of stress for you? *

Do you like to cook at home or prefer to eat out? *

Which diets have you tried? *

What are your main health concerns? *

What are your main health goals? *

Please list serious illnesses, hospitalizations and injuries: *

Please list any medications / prescriptions you are currently taking: *

Please list any vitamin and mineral supplements you are currently taking: *

Please list any allergies or sensitivities you have noticed: *

Please tell me about your mother's health: *

Please tell me about your father's health: *

Do you suffer from any of the following: (Check all that apply) *

Thank you for taking valuable time out of your day to focus on you! Is there anything else you would like to share with me?