EmailMeForm
Name
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Address
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How often do you check e-mail? (daily, weekly)
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Home Phone
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Work Phone
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Cell Phone
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Age
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Height
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Date of Birth
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Place of Birth
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Current Weight
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Weight 6 months ago
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Weight one year ago
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Would you like your weight to be different?
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Yes
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If so, what?
Social Information
Relationship Status
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Single
Married
Divorced/Widowed
Do you have children?
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Do you have pets?
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Occupation
Hours of work per week
Health Information
Please list your main health concerns
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Other concerns and/or goals?
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At what point in your life did you feel best?
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Any serious illness, hospitalizations, injuries?
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How is/was the health of your mother?
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How is/was the health of your father?
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What is your ancestry? (health issues, bloodlines)
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What blood type are you?
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Do you sleep well?
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Yes
No
How many hours?
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Do you wake up at night?
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Yes
No
If yes, why? Describe in detail.
Any pain, stiffness or swelling?
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Yes
No
Constipation, Diarrhea, Gas?
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Yes
No
Allergies or sensitivities? Please explain
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Medical Information
Do you take any supplements or medications?
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Yes
No
Please List
Any healers, helpers, pets or therapies with which you are involved?
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No
Please List
What role do sports and exercise play in your life?
Food Information
What foods did you eat often as a child?
Breakfast
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Lunch
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Dinner
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Snacks
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Liquid
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What's your food like these days?
Breakfast
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Lunch
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Dinner
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Snacks
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Liquid
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Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
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Yes
No
Do you cook?
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Yes
No
What percentage of your food is home cooked?
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What percentage is not?
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Where do you get the rest from?
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Do you crave sugar, coffee, cigarettes, or have any major addictions?
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The most important thing I should change about my diet to improve my health is
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Additional Comments
Anything else you would like to share?