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Consultation
Get a health consultation!
Select your gender and fill out the corresponding form.
Female Health Consultation
Female Health Consultation
Email Address
*
How often do you check email?
*
Daily
Weekly
Infrequent
Phone
*
(###)
###
####
What type of number is this?
*
Home
Work
Mobile
Age
Height
Birthdate
MM
DD
YYYY
Place of Birth
Current Weight
Weight 6 Months Ago
Weight 1 Year Ago
Would you like your weight to be different?
Yes
No
If so, what would you like your weight to be?
Social Information
Relationship Status
Single
In a relationship
Engaged
Married
In a civil union
In a domestic partnership
In an open relationship
It's complicated
Separated
Divorced
Widowed
Where do you currently live?
Number of Children
Number of Pets
Occupation
Hours of Work Per Week
Health Information
Please list your main health concerns
Other concerns and/or goals
At what point in your life did you feel 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?
How is your sleep?
How many hours of sleep do you get per night (average)?
Do you wake up at night?
Yes
No
Why?
Any of the following?
Select as many as apply
Pain
Stiffness
Swelling
Constipation
Diarrhea
Gas
Allergies
Sensitivities
Please explain
Women's Health
Are your periods regular?
Yes
No
How many days is your flow?
How frequent?
Painful or symptomatic? Please explain
Reached or approaching menopause? Please explain
Birth control history
Do you experience yeast infections or urinary tract infections? Please explain
Medical Information
Do you take any supplements or medications? Please list
Any healers, helpers, or therapies with which you are involved? Please list
What role do sports and exercise play in your life?
Food Information
Section 5
What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snacks
Liquids
Section 6
What is your food like these days?
Breakfast
Lunch
Dinner
Snacks
Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Yes
No
Maybe
Do you cook?
Yes
No
What percentage of your food is home-cooked?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions? Please explain
The most important thing I should do to improve my health is...
Additional Comments
Anything else you would like to share?
Thank you!
Male Health Consultation
Male Health Consultation
Name
*
First Name
Last Name
Email Address
*
How often do you check email?
Daily
Weekly
Infrequent
Phone
*
(###)
###
####
What type of number is this?
*
Home
Work
Mobile
Age
Height
Birthdate
MM
DD
YYYY
Place of Birth
Current Weight
Weight 6 Months Ago
Weight 1 Year Ago
Would you like your weight to be different?
Yes
No
If so, what would you like your weight to be?
Social Information
Relationship Status
Single
In a relationship
Engaged
Married
In a civil union
In a domestic partnership
In an open relationship
It's complicated
Separated
Divorced
Widowed
Where do you currently live?
Number of Children
Number of Pets
Occupation
Hours of Work Per Week
Health Information
Please list your main health concerns
Other concerns and/or goals
At what point in your life did you feel 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 of sleep do you get per night (average)?
Do you wake up at night?
Yes
No
Why?
Any of the following?
Select all that apply
Pain
Stiffness
Swelling
Constipation
Diarrhea
Gas
Allergies
Sensitivities
Please Explain
Medical Information
Do you take any supplements or medications? Please list
Any healers, helpers, or therapies with which you are involved? Please list
What role do sports and exercise play in your life?
Food Information
What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snacks
Liquids
What is your food like these days?
Breakfast
Lunch
Dinner
Snacks
Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Yes
No
Maybe
Do you cook?
Yes
No
What percentage of your food is home-cooked?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions? Please explain
The most important thing I should do to improve my health is...
Additional Information
Anything else you would like to share?
Thank you!
