NEW CLIENT QUESTIONNAIRE

CLIENT BACKGROUND

HEALTH HISTORY:

FULL NAME:_______________________________________________________________________________AGE: _______ DATE OF BIRTH: _______ HEIGHT: _______ GENDER: _________ADDRESS: ________________________________________ EMAIL: ______________________________ ________________________________________ PHONE (H:) ____________________ (C:)_________________ BEST CONTACT?_______________

CURRENT WEIGHT : _______ 6-MONTHS AGO? _______ 1-YEAR AGO? _____ARE YOU LOOKING TO: ___ LOSE ___ GAIN ___ MAINTAINHOW MUCH? _______ TIME FRAME? ______

PLEASE LIST YOUR MAIN HEALTH CONCERNS/SYMPTOMS: ____________________________________________________________________________________________________________________________________________________________________________________HOW LONG HAVE YOU EXPERIENCED THESE? __________________________________________________________________________________________ARE THERE ANY FACTORS THAT MAY HAVE/CONTINUE TO PERPETUATE THIS CONDITION? ____________________________________________________________________________________________________________________________________________________________________________________HAVE YOU CONSULTED ANY OF THE FOLLOWING FOR THIS? __ YES / NO ____ MEDICAL DOCTOR __ NATUROPATH __ DIETICIAN __ OTHER PLEASE DESCRIBE THEIR TREATMENT PROTOCOL: ____________________________________________________________________________________________________________________________________________________________________________________HAVE YOU USED/TRIED ANY OF THE FOLLOWING TREATMENTS?__ DIET MODIFICATION __ VITES/SUPPS __ HOMEOPATHY/TCM __ CHIROPRACTOR__ ACUPUNCTURE __ Rx DRUGS __ NATUROPATHY __ ACUPUNCTURE

CURRENT RELATIONSHIP STATUS: _________________________________________________________NAME OF SPOUSE: __________________________ CHILDREN? ______________ AGES?___________ OCCUPATION: ___________________ SHIFT WORK? ______ DO YOU ENJOY WORK? ___________LEVEL OF STRESS: @ HOME (1=LOW-10= HIGH) ________ @ WORK ________MAJOR CAUSES OF STRESS: _________________________________________________________________________________________

HOURS PER DAY SPENT: WORKING: _______ TRAVELING: _______ SITTING: _______ COMPUTER/TV: _______HOW WOULD YOU RATE YOUR HEALTH? __ EXCELLENT __ GOOD __ FAIR __ POOR PLEASE LIST ALL KNOWN FOOD ALLERGIES & SENSITIVITIES

PLEASE LIST ALL PERTINENT/CURRENT SUPPLEMENTS & PRESCRIPTIONS:

HAVE YOU RECENTLY TAKEN ANTIBIOTICS? _______ LENGTH OF USE? _______ WHAT IS YOUR BLOOD TYPE? ___ A ___ B ___ AB ___ O HOW IS/WAS THE HEALTH OF YOUR PARENTS? _________________________________________________________________________________________FAMILY HISTORY OF PARTICULAR DISEASE/SYMPTOM? : _________________________________________________________________________________________

GENERAL ENERGY (1= Low | 10= High) _____ HIGHEST? _____ LOWEST? ______DO YOU SUFFER FROM ANY OF THE FOLLOWING?__ SEASONAL ALLERGIES __ CONSTIPATION __ GALL/KIDNEY STONES__ ANXIETY __ DRY FLAKY SKIN __ GOUT __ LOW LIBIDO__ BAD BREATH/ODOR __ DIARRHEA __ HEADACHES __ POOR MEMORY__ BLOATING/PUFFINESS __ DIFFICULT URINATION __ IRRITABILITY __ WEIGHT LOSS__ COLD HANDS/FEET __ FREQ. URINATION __ JOINT PAIN __ WEIGHT GAIN

HOW MANY TIMES PER DAY DO YOU: SMOKE: _____ DRINK ALCOHOL: _______ DRINK COFFEE: _______HOW OFTEN DO YOU EXERCISE? __ 1-2 DAYS PER WEEK 3-4 DPW 5-7 DPWDURATION & INTENSITY/TYPE OF WORKOUT: ______________________________HOURS OF SLEEP? ________ DIFFICULTY FALLING ASLEEP? ______ STAYING ASLEEP? ________WHAT TIME DO YOU WAKE? _________ GO TO SLEEP? _______

HAVE YOU SUFFERED/BEEN DIAGNOSED FROM ANY OF THE FOLLOWING? (Mark with an ‘X’)__ ALCOHOLISM __ CANCER __ DIABETES I __ FIBROMYALGIA __ HYPO-__ ALZHEIMERS __ HEART DISEASE __ DIABETES II __ HEP A THYROID__ ANEMIA __ CELIACS __ DIGESTIVE ISSUES __ HEP B __ MIGRAINES__ ASTHMA __ FATIGUE __ EMO. EATING __ HEP C __ NEURODE-__ AUTO-IMMUNE __ COLITIS __ ECZEMA __ HIGH BP GENERATIVE __ BRONCHITIS __ DEPRESSION __ EPILEPSY __ HIGH CHOL.__ BILIARY DISEASE __ DEMENTIA __ EBV __ HYPER-THYROID

APPROXIMATE GLASSES/OUNCES WATER PER DAY? _______ IS IT FILTERED? ___________________

DO YOU CATEGORIZE YOURSELF AS FOLLOWING A DIET:__ LOW CARB __ LOW FAT __ GLUTEN FREE __ HIGH CARB __ HIGH PROTEIN__ PALEO __ PESCATARIAN __ RAW __ VEGETARIAN __ VEGANOTHER? ___________________________

RATE THE FREQUENCY YOU USE THE FOLLOWING (1 = LOW | 10= HIGH) __ ARTIFICIAL SWEETENERS __ SALTY JUNK FOOD __ PROTEIN BARS/SHAKES__ BEANS/LEGUMES __ MILK ALTERNATIVES __ REFINED FLOURS__ DAIRY/CHEESE __ NON-STARCHY VEG. __ SWEET SNACKS__ FRUIT __ NUTS/SEEDS ___ STARCHY VEG.__ LEAFY GREENS __ PROCESSED DELI MEATS ___ WHOLE GRAINS

WHAT TIME DO YOU EAT: BREAKFAST _____ LUNCH: ____ DINNER: ____ SNACK(S:) _____________DO YOU PRIMARILY PREPARE or PURCHASE YOUR SNACKS/MEALS? ___________________________________________________________________________________________HOW WOULD YOU RATE YOUR CULINARY KNOWLEDGE/ EXPERIENCE? (1=NOVICE | 10= PRO) _____WHAT ARE WOULD YOU SAY ARE YOUR BIGGEST INHIBITORS FOR EATING HEALTHIER? _______________________________________________MOST OF YOUR MEALS TAKE PLACE: (PLEASE CIRCLE)

RESTAURANT HOME ALONE FAST FOOD CAR/ON THE GO STANDING FAMILY

TYPICAL DAY OF MEALS: • BREAKFAST: _______________________________________________________________________ • LUNCH: ___________________________________________________________________________ • DINNER: __________________________________________________________________________ • SNACKS: __________________________________________________________________________

WHAT ARE YOUR FAVORITE RESTAURANTs or CUISINES?__ AMERICAN/ BURGERS __ DINER/COMFORT __ JAPANESE/ SUSHI __ SOUL FOOD__ BBQ __ FRENCH __ MEXICAN __ SPANISH__ CHINESE __ HEALTHY/ORGANIC __ MEDITERRANEAN __ PUB__ DELI __ ITALIAN __ MIDDLE EASTERN __ VEGAN

PLEASE LIST 2-3 RESTAURANTS WHERE YOU DINE OFTEN: ___________________________________________________________________________________________LIST 2-3 OF YOUR FAVORITE DISHES TO ORDER OUT: ______________________________________________________________________________________________________________________________________________________________________________________LIST 2-3 OF YOUR FAVORITE DISHES TO MAKE AT HOME: ______________________________________________________________________________________________________________________________________________________________________________________FOOD SENSITIVITIES/AVERSIONS/AVOIDANCE? ___________________________________________________________________________________________WHAT FOODS ARE YOU NOT WILLING TO GIVE UP? _____________________________________________DO YOU CRAVE FOODS THAT ARE HIGH IN:__ CHOCOLATE __ CARBS __ FAT __ PROTEIN __ SALT __ SUGAR

DO YOU SUFFER FROM ANY OF ThE FOLLOWING FOOD SENSITIVITIES ? __ EGGS __ FISH __ ONIONS __ PEPPERS __ TOMATOES__ EGGPLANT __ GARLIC __ MUSHROOMS __ SHELLFISH __ TREE NUTS__ DAIRY __ GLUTEN __PEANUTS __ SOY __ WHEATOTHER: _______________________________________ PLEASE CHECK THOSE YOU ENJOY & CROSS OUT THOSE YOU DISLIKE: __ BISON __ FISH __ PORK __ SHELLFISH __ VEAL__ CHICKEN __ GOAT/LAMB __ RED MEAT __ TURKEY __ VEGANPLEASE LIST YOUR FAVORITE TYPES OF FISH/SHELL-FISH:_____________________________________________

HOW OFTEN DO YOU CONSUME THE FOLLOWING PER WEEK? ___ EGG WHITES ___ GOAT CHEESE ___ MILK ALT. ___ PECORINO ___ EGG YOLKS ___ GREEK YOGURT ___ 2% MILK ___ Other Cheeses?___ FETA CHEESE ___ KEFIR ___ PARMESANPLEASE LIST THE FOLLOWING:FAVORITE PASTA SAUCE (s:) ________________________________________________________________FAVORITE SOUP (S:) ________________________________________________________________________FAVORITE SALAD DRESSING (S:) ____________________________________________________________

PLEASE CHECK ALL VEGETABLES YOU ENJOY EATING & CROSS OUT THOSE YOU DISLIKE: __ ARTICHOKES __ BRUSSEL SPROUTS __ CORN __ FENNEL __ PEAS __ ASPARAGUS __ CABBAGE __ CUCUMBER __ KALE __ PEPPER__ ARUGULA __ CAULIFLOWER __ DANDELION __ MUSHROOM __ POTATO __ BEETS __ CARROTS __ EGGPLANT __ NORI __ SQUASH __ BROCCOLI __ CELERY __ ESCAROLE __ PALM HEART __ SPINACH __ ZUCCHINIPLEASE CHECK ALL FRUITS YOU ENJOY EATING & CROSS OUT THOSE YOU DISLIKE: __ APPLES __ BLACKBERRIES __ PEACHES __ GRAPES __ NECTARINES __ APRICOTS __ BLUEBERRIES __ PLUMS __ KIWI __ ORANGES __ AVOCADO __ CANTALOUPE __ FIGS __ LYCHEE __ OLIVES __ BANANA __ CHERRIES __ GRAPEFRUIT __ MANGO __ PEARS__ WATERMLN __ CLEMENTINESPLEASE CHECK ALL HERBS/SPICES YOU ENJOY EATING & CROSS OUT THOSE YOU DISLIKE: __ ALLSPICE __ CILANTRO __ COCONUT __ DILL __ JERK __ ONION __ BASIL __ CHILES __ CUMIN __ GARLIC __ LEMON __ ORANGE __ BAY LEAF __ CINNAMON __ CURRY __ GINGER __ NUTMEG __ OREGANO __ THYME __ PARSLEY __ ROSEMARY PLEASE CHECK ALL YOU ENJOY EATING: __ ALMONDS __ BUCKWHEAT __ BLACK EYED __ FARRO __ LENTILS __ PEANUTS __ BARLEY __ BULGUR __ PEAS __ HAZELNUTS __ OATS __ PINE NUTS __ BLACKBEANS __ BRAZIL NUTS __ CHICKPEAS __ KIDNEY BEANS __ PECANS __ WALNUTS __ QUINOA __ SPELT __ BEANS DO YOU FEEL YOURSELF MINDLESSLY SNACKING DURING THE DAY? YES / NO IF YES, WHAT TIME(S:) ___________________________________________________________________________________DO YOU SUFFER FROM ANY SYMPTOMS BEFORE OR AFTER MEALS? PLEASE SPECIFY...___________________________________________________________________________________________ANYTHING ELSE YOU THINK I SHOULD KNOW? _________________________________________________________________________________________________________________________________________

PAGE 1

ALLERGY/SENSITIVITY SYMPTOMS TREATMENT?

NAME DOSE LENGTH OF USE PRESCRIBED? CURRENT?

PAGE 2

FULL NAME:_______________________________________________________________________________AGE: _______ DATE OF BIRTH: _______ HEIGHT: _______ GENDER: _________ADDRESS: ________________________________________ EMAIL: ______________________________ ________________________________________ PHONE (H:) ____________________ (C:)_________________ BEST CONTACT?_______________

CURRENT WEIGHT : _______ 6-MONTHS AGO? _______ 1-YEAR AGO? _____ARE YOU LOOKING TO: ___ LOSE ___ GAIN ___ MAINTAINHOW MUCH? _______ TIME FRAME? ______

PLEASE LIST YOUR MAIN HEALTH CONCERNS/SYMPTOMS: ____________________________________________________________________________________________________________________________________________________________________________________HOW LONG HAVE YOU EXPERIENCED THESE? __________________________________________________________________________________________ARE THERE ANY FACTORS THAT MAY HAVE/CONTINUE TO PERPETUATE THIS CONDITION? ____________________________________________________________________________________________________________________________________________________________________________________HAVE YOU CONSULTED ANY OF THE FOLLOWING FOR THIS? __ YES / NO ____ MEDICAL DOCTOR __ NATUROPATH __ DIETICIAN __ OTHER PLEASE DESCRIBE THEIR TREATMENT PROTOCOL: ____________________________________________________________________________________________________________________________________________________________________________________HAVE YOU USED/TRIED ANY OF THE FOLLOWING TREATMENTS?__ DIET MODIFICATION __ VITES/SUPPS __ HOMEOPATHY/TCM __ CHIROPRACTOR__ ACUPUNCTURE __ Rx DRUGS __ NATUROPATHY __ ACUPUNCTURE

CURRENT RELATIONSHIP STATUS: _________________________________________________________NAME OF SPOUSE: __________________________ CHILDREN? ______________ AGES?___________ OCCUPATION: ___________________ SHIFT WORK? ______ DO YOU ENJOY WORK? ___________LEVEL OF STRESS: @ HOME (1=LOW-10= HIGH) ________ @ WORK ________MAJOR CAUSES OF STRESS: _________________________________________________________________________________________

HOURS PER DAY SPENT: WORKING: _______ TRAVELING: _______ SITTING: _______ COMPUTER/TV: _______HOW WOULD YOU RATE YOUR HEALTH? __ EXCELLENT __ GOOD __ FAIR __ POOR PLEASE LIST ALL KNOWN FOOD ALLERGIES & SENSITIVITIES

PLEASE LIST ALL PERTINENT/CURRENT SUPPLEMENTS & PRESCRIPTIONS:

HAVE YOU RECENTLY TAKEN ANTIBIOTICS? _______ LENGTH OF USE? _______ WHAT IS YOUR BLOOD TYPE? ___ A ___ B ___ AB ___ O HOW IS/WAS THE HEALTH OF YOUR PARENTS? _________________________________________________________________________________________FAMILY HISTORY OF PARTICULAR DISEASE/SYMPTOM? : _________________________________________________________________________________________

GENERAL ENERGY (1= Low | 10= High) _____ HIGHEST? _____ LOWEST? ______DO YOU SUFFER FROM ANY OF THE FOLLOWING?__ SEASONAL ALLERGIES __ CONSTIPATION __ GALL/KIDNEY STONES__ ANXIETY __ DRY FLAKY SKIN __ GOUT __ LOW LIBIDO__ BAD BREATH/ODOR __ DIARRHEA __ HEADACHES __ POOR MEMORY__ BLOATING/PUFFINESS __ DIFFICULT URINATION __ IRRITABILITY __ WEIGHT LOSS__ COLD HANDS/FEET __ FREQ. URINATION __ JOINT PAIN __ WEIGHT GAIN

HOW MANY TIMES PER DAY DO YOU: SMOKE: _____ DRINK ALCOHOL: _______ DRINK COFFEE: _______HOW OFTEN DO YOU EXERCISE? __ 1-2 DAYS PER WEEK 3-4 DPW 5-7 DPWDURATION & INTENSITY/TYPE OF WORKOUT: ______________________________HOURS OF SLEEP? ________ DIFFICULTY FALLING ASLEEP? ______ STAYING ASLEEP? ________WHAT TIME DO YOU WAKE? _________ GO TO SLEEP? _______

HAVE YOU SUFFERED/BEEN DIAGNOSED FROM ANY OF THE FOLLOWING? (Mark with an ‘X’)__ ALCOHOLISM __ CANCER __ DIABETES I __ FIBROMYALGIA __ HYPO-__ ALZHEIMERS __ HEART DISEASE __ DIABETES II __ HEP A THYROID__ ANEMIA __ CELIACS __ DIGESTIVE ISSUES __ HEP B __ MIGRAINES__ ASTHMA __ FATIGUE __ EMO. EATING __ HEP C __ NEURODE-__ AUTO-IMMUNE __ COLITIS __ ECZEMA __ HIGH BP GENERATIVE __ BRONCHITIS __ DEPRESSION __ EPILEPSY __ HIGH CHOL.__ BILIARY DISEASE __ DEMENTIA __ EBV __ HYPER-THYROID

APPROXIMATE GLASSES/OUNCES WATER PER DAY? _______ IS IT FILTERED? ___________________

DO YOU CATEGORIZE YOURSELF AS FOLLOWING A DIET:__ LOW CARB __ LOW FAT __ GLUTEN FREE __ HIGH CARB __ HIGH PROTEIN__ PALEO __ PESCATARIAN __ RAW __ VEGETARIAN __ VEGANOTHER? ___________________________

RATE THE FREQUENCY YOU USE THE FOLLOWING (1 = LOW | 10= HIGH) __ ARTIFICIAL SWEETENERS __ SALTY JUNK FOOD __ PROTEIN BARS/SHAKES__ BEANS/LEGUMES __ MILK ALTERNATIVES __ REFINED FLOURS__ DAIRY/CHEESE __ NON-STARCHY VEG. __ SWEET SNACKS__ FRUIT __ NUTS/SEEDS ___ STARCHY VEG.__ LEAFY GREENS __ PROCESSED DELI MEATS ___ WHOLE GRAINS

WHAT TIME DO YOU EAT: BREAKFAST _____ LUNCH: ____ DINNER: ____ SNACK(S:) _____________DO YOU PRIMARILY PREPARE or PURCHASE YOUR SNACKS/MEALS? ___________________________________________________________________________________________HOW WOULD YOU RATE YOUR CULINARY KNOWLEDGE/ EXPERIENCE? (1=NOVICE | 10= PRO) _____WHAT ARE WOULD YOU SAY ARE YOUR BIGGEST INHIBITORS FOR EATING HEALTHIER? _______________________________________________MOST OF YOUR MEALS TAKE PLACE: (PLEASE CIRCLE)

RESTAURANT HOME ALONE FAST FOOD CAR/ON THE GO STANDING FAMILY

TYPICAL DAY OF MEALS: • BREAKFAST: _______________________________________________________________________ • LUNCH: ___________________________________________________________________________ • DINNER: __________________________________________________________________________ • SNACKS: __________________________________________________________________________

WHAT ARE YOUR FAVORITE RESTAURANTs or CUISINES?__ AMERICAN/ BURGERS __ DINER/COMFORT __ JAPANESE/ SUSHI __ SOUL FOOD__ BBQ __ FRENCH __ MEXICAN __ SPANISH__ CHINESE __ HEALTHY/ORGANIC __ MEDITERRANEAN __ PUB__ DELI __ ITALIAN __ MIDDLE EASTERN __ VEGAN

PLEASE LIST 2-3 RESTAURANTS WHERE YOU DINE OFTEN: ___________________________________________________________________________________________LIST 2-3 OF YOUR FAVORITE DISHES TO ORDER OUT: ______________________________________________________________________________________________________________________________________________________________________________________LIST 2-3 OF YOUR FAVORITE DISHES TO MAKE AT HOME: ______________________________________________________________________________________________________________________________________________________________________________________FOOD SENSITIVITIES/AVERSIONS/AVOIDANCE? ___________________________________________________________________________________________WHAT FOODS ARE YOU NOT WILLING TO GIVE UP? _____________________________________________DO YOU CRAVE FOODS THAT ARE HIGH IN:__ CHOCOLATE __ CARBS __ FAT __ PROTEIN __ SALT __ SUGAR

DO YOU SUFFER FROM ANY OF ThE FOLLOWING FOOD SENSITIVITIES ? __ EGGS __ FISH __ ONIONS __ PEPPERS __ TOMATOES__ EGGPLANT __ GARLIC __ MUSHROOMS __ SHELLFISH __ TREE NUTS__ DAIRY __ GLUTEN __PEANUTS __ SOY __ WHEATOTHER: _______________________________________ PLEASE CHECK THOSE YOU ENJOY & CROSS OUT THOSE YOU DISLIKE: __ BISON __ FISH __ PORK __ SHELLFISH __ VEAL__ CHICKEN __ GOAT/LAMB __ RED MEAT __ TURKEY __ VEGANPLEASE LIST YOUR FAVORITE TYPES OF FISH/SHELL-FISH:_____________________________________________

HOW OFTEN DO YOU CONSUME THE FOLLOWING PER WEEK? ___ EGG WHITES ___ GOAT CHEESE ___ MILK ALT. ___ PECORINO ___ EGG YOLKS ___ GREEK YOGURT ___ 2% MILK ___ Other Cheeses?___ FETA CHEESE ___ KEFIR ___ PARMESANPLEASE LIST THE FOLLOWING:FAVORITE PASTA SAUCE (s:) ________________________________________________________________FAVORITE SOUP (S:) ________________________________________________________________________FAVORITE SALAD DRESSING (S:) ____________________________________________________________

PLEASE CHECK ALL VEGETABLES YOU ENJOY EATING & CROSS OUT THOSE YOU DISLIKE: __ ARTICHOKES __ BRUSSEL SPROUTS __ CORN __ FENNEL __ PEAS __ ASPARAGUS __ CABBAGE __ CUCUMBER __ KALE __ PEPPER__ ARUGULA __ CAULIFLOWER __ DANDELION __ MUSHROOM __ POTATO __ BEETS __ CARROTS __ EGGPLANT __ NORI __ SQUASH __ BROCCOLI __ CELERY __ ESCAROLE __ PALM HEART __ SPINACH __ ZUCCHINIPLEASE CHECK ALL FRUITS YOU ENJOY EATING & CROSS OUT THOSE YOU DISLIKE: __ APPLES __ BLACKBERRIES __ PEACHES __ GRAPES __ NECTARINES __ APRICOTS __ BLUEBERRIES __ PLUMS __ KIWI __ ORANGES __ AVOCADO __ CANTALOUPE __ FIGS __ LYCHEE __ OLIVES __ BANANA __ CHERRIES __ GRAPEFRUIT __ MANGO __ PEARS__ WATERMLN __ CLEMENTINESPLEASE CHECK ALL HERBS/SPICES YOU ENJOY EATING & CROSS OUT THOSE YOU DISLIKE: __ ALLSPICE __ CILANTRO __ COCONUT __ DILL __ JERK __ ONION __ BASIL __ CHILES __ CUMIN __ GARLIC __ LEMON __ ORANGE __ BAY LEAF __ CINNAMON __ CURRY __ GINGER __ NUTMEG __ OREGANO __ THYME __ PARSLEY __ ROSEMARY PLEASE CHECK ALL YOU ENJOY EATING: __ ALMONDS __ BUCKWHEAT __ BLACK EYED __ FARRO __ LENTILS __ PEANUTS __ BARLEY __ BULGUR __ PEAS __ HAZELNUTS __ OATS __ PINE NUTS __ BLACKBEANS __ BRAZIL NUTS __ CHICKPEAS __ KIDNEY BEANS __ PECANS __ WALNUTS __ QUINOA __ SPELT __ BEANS DO YOU FEEL YOURSELF MINDLESSLY SNACKING DURING THE DAY? YES / NO IF YES, WHAT TIME(S:) ___________________________________________________________________________________DO YOU SUFFER FROM ANY SYMPTOMS BEFORE OR AFTER MEALS? PLEASE SPECIFY...___________________________________________________________________________________________ANYTHING ELSE YOU THINK I SHOULD KNOW? _________________________________________________________________________________________________________________________________________

DIET & NUTRITION:

PAGE 3

FULL NAME:_______________________________________________________________________________AGE: _______ DATE OF BIRTH: _______ HEIGHT: _______ GENDER: _________ADDRESS: ________________________________________ EMAIL: ______________________________

________________________________________ PHONE (H:) ____________________ (C:)_________________ BEST CONTACT?_______________

CURRENT WEIGHT : _______ 6-MONTHS AGO? _______ 1-YEAR AGO? _____ARE YOU LOOKING TO: ___ LOSE ___ GAIN ___ MAINTAINHOW MUCH? _______ TIME FRAME? ______

PLEASE LIST YOUR MAIN HEALTH CONCERNS/SYMPTOMS: ____________________________________________________________________________________________________________________________________________________________________________________HOW LONG HAVE YOU EXPERIENCED THESE? __________________________________________________________________________________________ARE THERE ANY FACTORS THAT MAY HAVE/CONTINUE TO PERPETUATE THIS CONDITION? ____________________________________________________________________________________________________________________________________________________________________________________HAVE YOU CONSULTED ANY OF THE FOLLOWING FOR THIS? __ YES / NO ____ MEDICAL DOCTOR __ NATUROPATH __ DIETICIAN __ OTHER PLEASE DESCRIBE THEIR TREATMENT PROTOCOL: ____________________________________________________________________________________________________________________________________________________________________________________HAVE YOU USED/TRIED ANY OF THE FOLLOWING TREATMENTS?__ DIET MODIFICATION __ VITES/SUPPS __ HOMEOPATHY/TCM __ CHIROPRACTOR__ ACUPUNCTURE __ Rx DRUGS __ NATUROPATHY __ ACUPUNCTURE

CURRENT RELATIONSHIP STATUS: _________________________________________________________NAME OF SPOUSE: __________________________ CHILDREN? ______________ AGES?___________ OCCUPATION: ___________________ SHIFT WORK? ______ DO YOU ENJOY WORK? ___________LEVEL OF STRESS: @ HOME (1=LOW-10= HIGH) ________ @ WORK ________MAJOR CAUSES OF STRESS: _________________________________________________________________________________________

HOURS PER DAY SPENT: WORKING: _______ TRAVELING: _______ SITTING: _______ COMPUTER/TV: _______HOW WOULD YOU RATE YOUR HEALTH? __ EXCELLENT __ GOOD __ FAIR __ POOR PLEASE LIST ALL KNOWN FOOD ALLERGIES & SENSITIVITIES

PLEASE LIST ALL PERTINENT/CURRENT SUPPLEMENTS & PRESCRIPTIONS:

HAVE YOU RECENTLY TAKEN ANTIBIOTICS? _______ LENGTH OF USE? _______ WHAT IS YOUR BLOOD TYPE? ___ A ___ B ___ AB ___ O HOW IS/WAS THE HEALTH OF YOUR PARENTS? _________________________________________________________________________________________FAMILY HISTORY OF PARTICULAR DISEASE/SYMPTOM? : _________________________________________________________________________________________

GENERAL ENERGY (1= Low | 10= High) _____ HIGHEST? _____ LOWEST? ______DO YOU SUFFER FROM ANY OF THE FOLLOWING?__ SEASONAL ALLERGIES __ CONSTIPATION __ GALL/KIDNEY STONES__ ANXIETY __ DRY FLAKY SKIN __ GOUT __ LOW LIBIDO__ BAD BREATH/ODOR __ DIARRHEA __ HEADACHES __ POOR MEMORY__ BLOATING/PUFFINESS __ DIFFICULT URINATION __ IRRITABILITY __ WEIGHT LOSS__ COLD HANDS/FEET __ FREQ. URINATION __ JOINT PAIN __ WEIGHT GAIN

HOW MANY TIMES PER DAY DO YOU: SMOKE: _____ DRINK ALCOHOL: _______ DRINK COFFEE: _______HOW OFTEN DO YOU EXERCISE? __ 1-2 DAYS PER WEEK 3-4 DPW 5-7 DPWDURATION & INTENSITY/TYPE OF WORKOUT: ______________________________HOURS OF SLEEP? ________ DIFFICULTY FALLING ASLEEP? ______ STAYING ASLEEP? ________WHAT TIME DO YOU WAKE? _________ GO TO SLEEP? _______

HAVE YOU SUFFERED/BEEN DIAGNOSED FROM ANY OF THE FOLLOWING? __ ALCOHOLISM __ CANCER __ DIABETES I __ FIBROMYALGIA __ HYPO-__ ALZHEIMERS __ HEART DISEASE __ DIABETES II __ HEP A THYROID__ ANEMIA __ CELIACS __ DIGESTIVE ISSUES __ HEP B __ MIGRAINES__ ASTHMA __ FATIGUE __ EMO. EATING __ HEP C __ NEURODE-__ AUTO-IMMUNE __ COLITIS __ ECZEMA __ HIGH BP GENERATIVE __ BRONCHITIS __ DEPRESSION __ EPILEPSY __ HIGH CHOL.__ BILIARY DISEASE __ DEMENTIA __ EBV __ HYPER-THYROID

APPROXIMATE GLASSES/OUNCES WATER PER DAY? _______ IS IT FILTERED? ___________________

DO YOU CATEGORIZE YOURSELF AS FOLLOWING A DIET:__ LOW CARB __ LOW FAT __ GLUTEN FREE __ HIGH CARB __ HIGH PROTEIN__ PALEO __ PESCATARIAN __ RAW __ VEGETARIAN __ VEGANOTHER? ___________________________

RATE THE FREQUENCY YOU USE THE FOLLOWING (1 = LOW | 10= HIGH) __ ARTIFICIAL SWEETENERS __ SALTY JUNK FOOD __ PROTEIN BARS/SHAKES__ BEANS/LEGUMES __ MILK ALTERNATIVES __ REFINED FLOURS__ DAIRY/CHEESE __ NON-STARCHY VEG. __ SWEET SNACKS__ FRUIT __ NUTS/SEEDS ___ STARCHY VEG.__ LEAFY GREENS __ PROCESSED DELI MEATS ___ WHOLE GRAINS

WHAT TIME DO YOU EAT: BREAKFAST _____ LUNCH: ____ DINNER: ____ SNACK(S:) _____________DO YOU PRIMARILY PREPARE or PURCHASE YOUR SNACKS/MEALS? ___________________________________________________________________________________________HOW WOULD YOU RATE YOUR CULINARY KNOWLEDGE/ EXPERIENCE? (1=NOVICE | 10= PRO) _____WHAT ARE WOULD YOU SAY ARE YOUR BIGGEST INHIBITORS FOR EATING HEALTHIER? _______________________________________________MOST OF YOUR MEALS TAKE PLACE:

RESTAURANT HOME ALONE FAST FOOD CAR/ON THE GO STANDING FAMILY

TYPICAL DAY OF MEALS:• BREAKFAST: _______________________________________________________________________• LUNCH: ___________________________________________________________________________• DINNER: __________________________________________________________________________• SNACKS: __________________________________________________________________________

WHAT ARE YOUR FAVORITE RESTAURANTs or CUISINES?__ AMERICAN/ BURGERS __ DINER/COMFORT __ JAPANESE/ SUSHI __ SOUL FOOD__ BBQ __ FRENCH __ MEXICAN __ SPANISH__ CHINESE __ HEALTHY/ORGANIC __ MEDITERRANEAN __ PUB__ DELI __ ITALIAN __ MIDDLE EASTERN __ VEGAN

PLEASE LIST 2-3 RESTAURANTS WHERE YOU DINE OFTEN: ___________________________________________________________________________________________LIST 2-3 OF YOUR FAVORITE DISHES TO ORDER OUT: ______________________________________________________________________________________________________________________________________________________________________________________LIST 2-3 OF YOUR FAVORITE DISHES TO MAKE AT HOME: ______________________________________________________________________________________________________________________________________________________________________________________FOOD SENSITIVITIES/AVERSIONS/AVOIDANCE? ___________________________________________________________________________________________WHAT FOODS ARE YOU NOT WILLING TO GIVE UP? _____________________________________________DO YOU CRAVE FOODS THAT ARE HIGH IN:__ CHOCOLATE __ CARBS __ FAT __ PROTEIN __ SALT __ SUGAR

DO YOU SUFFER FROM ANY OF ThE FOLLOWING FOOD SENSITIVITIES ? __ EGGS __ FISH __ ONIONS __ PEPPERS __ TOMATOES__ EGGPLANT __ GARLIC __ MUSHROOMS __ SHELLFISH __ TREE NUTS__ DAIRY __ GLUTEN __PEANUTS __ SOY __ WHEATOTHER: _______________________________________ PLEASE CHECK THOSE YOU ENJOY & CROSS OUT THOSE YOU DISLIKE: __ BISON __ FISH __ PORK __ SHELLFISH __ VEAL__ CHICKEN __ GOAT/LAMB __ RED MEAT __ TURKEY __ VEGANPLEASE LIST YOUR FAVORITE TYPES OF FISH/SHELL-FISH:_____________________________________________

HOW OFTEN DO YOU CONSUME THE FOLLOWING PER WEEK? ___ EGG WHITES ___ GOAT CHEESE ___ MILK ALT. ___ PECORINO ___ EGG YOLKS ___ GREEK YOGURT ___ 2% MILK ___ Other Cheeses?___ FETA CHEESE ___ KEFIR ___ PARMESANPLEASE LIST THE FOLLOWING:FAVORITE PASTA SAUCE (s:) ________________________________________________________________FAVORITE SOUP (S:) ________________________________________________________________________FAVORITE SALAD DRESSING (S:) ____________________________________________________________

PLEASE CHECK ALL VEGETABLES YOU ENJOY EATING & CROSS OUT THOSE YOU DISLIKE: __ ARTICHOKES __ BRUSSEL SPROUTS __ CORN __ FENNEL __ PEAS __ ASPARAGUS __ CABBAGE __ CUCUMBER __ KALE __ PEPPER__ ARUGULA __ CAULIFLOWER __ DANDELION __ MUSHROOM __ POTATO __ BEETS __ CARROTS __ EGGPLANT __ NORI __ SQUASH __ BROCCOLI __ CELERY __ ESCAROLE __ PALM HEART __ SPINACH __ ZUCCHINIPLEASE CHECK ALL FRUITS YOU ENJOY EATING & CROSS OUT THOSE YOU DISLIKE: __ APPLES __ BLACKBERRIES __ PEACHES __ GRAPES __ NECTARINES __ APRICOTS __ BLUEBERRIES __ PLUMS __ KIWI __ ORANGES __ AVOCADO __ CANTALOUPE __ FIGS __ LYCHEE __ OLIVES __ BANANA __ CHERRIES __ GRAPEFRUIT __ MANGO __ PEARS__ WATERMLN __ CLEMENTINESPLEASE CHECK ALL HERBS/SPICES YOU ENJOY EATING & CROSS OUT THOSE YOU DISLIKE: __ ALLSPICE __ CILANTRO __ COCONUT __ DILL __ JERK __ ONION __ BASIL __ CHILES __ CUMIN __ GARLIC __ LEMON __ ORANGE __ BAY LEAF __ CINNAMON __ CURRY __ GINGER __ NUTMEG __ OREGANO __ THYME __ PARSLEY __ ROSEMARY PLEASE CHECK ALL YOU ENJOY EATING: __ ALMONDS __ BUCKWHEAT __ BLACK EYED __ FARRO __ LENTILS __ PEANUTS __ BARLEY __ BULGUR __ PEAS __ HAZELNUTS __ OATS __ PINE NUTS __ BLACKBEANS __ BRAZIL NUTS __ CHICKPEAS __ KIDNEY BEANS __ PECANS __ WALNUTS __ QUINOA __ SPELT __ BEANS DO YOU FEEL YOURSELF MINDLESSLY SNACKING DURING THE DAY? YES / NO IF YES, WHAT TIME(S:) ___________________________________________________________________________________DO YOU SUFFER FROM ANY SYMPTOMS BEFORE OR AFTER MEALS? PLEASE SPECIFY...___________________________________________________________________________________________ANYTHING ELSE YOU THINK I SHOULD KNOW? _________________________________________________________________________________________________________________________________________

PAGE 4

FULL NAME:_______________________________________________________________________________AGE: _______ DATE OF BIRTH: _______ HEIGHT: _______ GENDER: _________ADDRESS: ________________________________________ EMAIL: ______________________________

________________________________________ PHONE (H:) ____________________ (C:)_________________ BEST CONTACT?_______________

CURRENT WEIGHT : _______ 6-MONTHS AGO? _______ 1-YEAR AGO? _____ARE YOU LOOKING TO: ___ LOSE ___ GAIN ___ MAINTAINHOW MUCH? _______ TIME FRAME? ______

PLEASE LIST YOUR MAIN HEALTH CONCERNS/SYMPTOMS: ____________________________________________________________________________________________________________________________________________________________________________________HOW LONG HAVE YOU EXPERIENCED THESE? __________________________________________________________________________________________ARE THERE ANY FACTORS THAT MAY HAVE/CONTINUE TO PERPETUATE THIS CONDITION? ____________________________________________________________________________________________________________________________________________________________________________________HAVE YOU CONSULTED ANY OF THE FOLLOWING FOR THIS? __ YES / NO ____ MEDICAL DOCTOR __ NATUROPATH __ DIETICIAN __ OTHER PLEASE DESCRIBE THEIR TREATMENT PROTOCOL: ____________________________________________________________________________________________________________________________________________________________________________________HAVE YOU USED/TRIED ANY OF THE FOLLOWING TREATMENTS?__ DIET MODIFICATION __ VITES/SUPPS __ HOMEOPATHY/TCM __ CHIROPRACTOR__ ACUPUNCTURE __ Rx DRUGS __ NATUROPATHY __ ACUPUNCTURE

CURRENT RELATIONSHIP STATUS: _________________________________________________________NAME OF SPOUSE: __________________________ CHILDREN? ______________ AGES?___________ OCCUPATION: ___________________ SHIFT WORK? ______ DO YOU ENJOY WORK? ___________LEVEL OF STRESS: @ HOME (1=LOW-10= HIGH) ________ @ WORK ________MAJOR CAUSES OF STRESS: _________________________________________________________________________________________

HOURS PER DAY SPENT: WORKING: _______ TRAVELING: _______ SITTING: _______ COMPUTER/TV: _______HOW WOULD YOU RATE YOUR HEALTH? __ EXCELLENT __ GOOD __ FAIR __ POOR PLEASE LIST ALL KNOWN FOOD ALLERGIES & SENSITIVITIES

PLEASE LIST ALL PERTINENT/CURRENT SUPPLEMENTS & PRESCRIPTIONS:

HAVE YOU RECENTLY TAKEN ANTIBIOTICS? _______ LENGTH OF USE? _______ WHAT IS YOUR BLOOD TYPE? ___ A ___ B ___ AB ___ O HOW IS/WAS THE HEALTH OF YOUR PARENTS? _________________________________________________________________________________________FAMILY HISTORY OF PARTICULAR DISEASE/SYMPTOM? : _________________________________________________________________________________________

GENERAL ENERGY (1= Low | 10= High) _____ HIGHEST? _____ LOWEST? ______DO YOU SUFFER FROM ANY OF THE FOLLOWING?__ SEASONAL ALLERGIES __ CONSTIPATION __ GALL/KIDNEY STONES__ ANXIETY __ DRY FLAKY SKIN __ GOUT __ LOW LIBIDO__ BAD BREATH/ODOR __ DIARRHEA __ HEADACHES __ POOR MEMORY__ BLOATING/PUFFINESS __ DIFFICULT URINATION __ IRRITABILITY __ WEIGHT LOSS__ COLD HANDS/FEET __ FREQ. URINATION __ JOINT PAIN __ WEIGHT GAIN

HOW MANY TIMES PER DAY DO YOU: SMOKE: _____ DRINK ALCOHOL: _______ DRINK COFFEE: _______HOW OFTEN DO YOU EXERCISE? __ 1-2 DAYS PER WEEK 3-4 DPW 5-7 DPWDURATION & INTENSITY/TYPE OF WORKOUT: ______________________________HOURS OF SLEEP? ________ DIFFICULTY FALLING ASLEEP? ______ STAYING ASLEEP? ________WHAT TIME DO YOU WAKE? _________ GO TO SLEEP? _______

HAVE YOU SUFFERED/BEEN DIAGNOSED FROM ANY OF THE FOLLOWING? (Mark with an ‘X’)__ ALCOHOLISM __ CANCER __ DIABETES I __ FIBROMYALGIA __ HYPO-__ ALZHEIMERS __ HEART DISEASE __ DIABETES II __ HEP A THYROID__ ANEMIA __ CELIACS __ DIGESTIVE ISSUES __ HEP B __ MIGRAINES__ ASTHMA __ FATIGUE __ EMO. EATING __ HEP C __ NEURODE-__ AUTO-IMMUNE __ COLITIS __ ECZEMA __ HIGH BP GENERATIVE __ BRONCHITIS __ DEPRESSION __ EPILEPSY __ HIGH CHOL.__ BILIARY DISEASE __ DEMENTIA __ EBV __ HYPER-THYROID

APPROXIMATE GLASSES/OUNCES WATER PER DAY? _______ IS IT FILTERED? ___________________

DO YOU CATEGORIZE YOURSELF AS FOLLOWING A DIET:__ LOW CARB __ LOW FAT __ GLUTEN FREE __ HIGH CARB __ HIGH PROTEIN__ PALEO __ PESCATARIAN __ RAW __ VEGETARIAN __ VEGANOTHER? ___________________________

RATE THE FREQUENCY YOU USE THE FOLLOWING (1 = LOW | 10= HIGH) __ ARTIFICIAL SWEETENERS __ SALTY JUNK FOOD __ PROTEIN BARS/SHAKES__ BEANS/LEGUMES __ MILK ALTERNATIVES __ REFINED FLOURS__ DAIRY/CHEESE __ NON-STARCHY VEG. __ SWEET SNACKS__ FRUIT __ NUTS/SEEDS ___ STARCHY VEG.__ LEAFY GREENS __ PROCESSED DELI MEATS ___ WHOLE GRAINS

WHAT TIME DO YOU EAT: BREAKFAST _____ LUNCH: ____ DINNER: ____ SNACK(S:) _____________DO YOU PRIMARILY PREPARE or PURCHASE YOUR SNACKS/MEALS? ___________________________________________________________________________________________HOW WOULD YOU RATE YOUR CULINARY KNOWLEDGE/ EXPERIENCE? (1=NOVICE | 10= PRO) _____WHAT ARE WOULD YOU SAY ARE YOUR BIGGEST INHIBITORS FOR EATING HEALTHIER? _______________________________________________MOST OF YOUR MEALS TAKE PLACE: (PLEASE CIRCLE)

RESTAURANT HOME ALONE FAST FOOD CAR/ON THE GO STANDING FAMILY

TYPICAL DAY OF MEALS:• BREAKFAST: _______________________________________________________________________• LUNCH: ___________________________________________________________________________• DINNER: __________________________________________________________________________• SNACKS: __________________________________________________________________________

WHAT ARE YOUR FAVORITE RESTAURANTs or CUISINES?__ AMERICAN/ BURGERS __ DINER/COMFORT __ JAPANESE/ SUSHI __ SOUL FOOD__ BBQ __ FRENCH __ MEXICAN __ SPANISH__ CHINESE __ HEALTHY/ORGANIC __ MEDITERRANEAN __ PUB__ DELI __ ITALIAN __ MIDDLE EASTERN __ VEGAN

PLEASE LIST 2-3 RESTAURANTS WHERE YOU DINE OFTEN: ___________________________________________________________________________________________LIST 2-3 OF YOUR FAVORITE DISHES TO ORDER OUT: ______________________________________________________________________________________________________________________________________________________________________________________LIST 2-3 OF YOUR FAVORITE DISHES TO MAKE AT HOME: ______________________________________________________________________________________________________________________________________________________________________________________FOOD SENSITIVITIES/AVERSIONS/AVOIDANCE? ___________________________________________________________________________________________WHAT FOODS ARE YOU NOT WILLING TO GIVE UP? _____________________________________________DO YOU CRAVE FOODS THAT ARE HIGH IN:__ CHOCOLATE __ CARBS __ FAT __ PROTEIN __ SALT __ SUGAR

DO YOU SUFFER FROM ANY OF ThE FOLLOWING FOOD SENSITIVITIES ? __ EGGS __ FISH __ ONIONS __ PEPPERS __ TOMATOES__ EGGPLANT __ GARLIC __ MUSHROOMS __ SHELLFISH __ TREE NUTS__ DAIRY __ GLUTEN __PEANUTS __ SOY __ WHEAT

__ PORK

OTHER: _______________________________________ PLEASE CHECK THOSE YOU CONSUME: : __ BISON __ FISH __ SHELLFISH __ VEAL__ CHICKEN __ GOAT/LAMB __ RED MEAT __ TURKEY __ VEGANPLEASE LIST YOUR FAVORITE TYPES OF FISH/SHELL-FISH:_____________________________________________

HOW OFTEN DO YOU CONSUME THE FOLLOWING PER WEEK? ___ EGG WHITES ___ GOAT CHEESE ___ MILK ALT. ___ PECORINO ___ EGG YOLKS ___ GREEK YOGURT ___ 2% MILK ___ Other Cheeses?___ FETA CHEESE ___ KEFIR ___ PARMESANPLEASE LIST THE FOLLOWING:FAVORITE PASTA SAUCE (s:) ________________________________________________________________FAVORITE SOUP (S:) ________________________________________________________________________FAVORITE SALAD DRESSING (S:) ____________________________________________________________

PLEASE CHECK ALL VEGETABLES YOU ENJOY EATING & CROSS OUT THOSE YOU DISLIKE: __ ARTICHOKES __ BRUSSEL SPROUTS __ CORN __ FENNEL __ PEAS __ ASPARAGUS __ CABBAGE __ CUCUMBER __ KALE __ PEPPER__ ARUGULA __ CAULIFLOWER __ DANDELION __ MUSHROOM __ POTATO __ BEETS __ CARROTS __ EGGPLANT __ NORI __ SQUASH __ BROCCOLI __ CELERY __ ESCAROLE __ PALM HEART __ SPINACH __ ZUCCHINIPLEASE CHECK ALL FRUITS YOU ENJOY EATING & CROSS OUT THOSE YOU DISLIKE: __ APPLES __ BLACKBERRIES __ PEACHES __ GRAPES __ NECTARINES __ APRICOTS __ BLUEBERRIES __ PLUMS __ KIWI __ ORANGES __ AVOCADO __ CANTALOUPE __ FIGS __ LYCHEE __ OLIVES __ BANANA __ CHERRIES __ GRAPEFRUIT __ MANGO __ PEARS__ WATERMLN __ CLEMENTINESPLEASE CHECK ALL HERBS/SPICES YOU ENJOY EATING & CROSS OUT THOSE YOU DISLIKE: __ ALLSPICE __ CILANTRO __ COCONUT __ DILL __ JERK __ ONION __ BASIL __ CHILES __ CUMIN __ GARLIC __ LEMON __ ORANGE __ BAY LEAF __ CINNAMON __ CURRY __ GINGER __ NUTMEG __ OREGANO __ THYME __ PARSLEY __ ROSEMARY PLEASE CHECK ALL YOU ENJOY EATING: __ ALMONDS __ BUCKWHEAT __ BLACK EYED __ FARRO __ LENTILS __ PEANUTS __ BARLEY __ BULGUR __ PEAS __ HAZELNUTS __ OATS __ PINE NUTS __ BLACKBEANS __ BRAZIL NUTS __ CHICKPEAS __ KIDNEY BEANS __ PECANS __ WALNUTS __ QUINOA __ SPELT __ BEANS DO YOU FEEL YOURSELF MINDLESSLY SNACKING DURING THE DAY? YES / NO IF YES, WHAT TIME(S:) ___________________________________________________________________________________DO YOU SUFFER FROM ANY SYMPTOMS BEFORE OR AFTER MEALS? PLEASE SPECIFY...___________________________________________________________________________________________ANYTHING ELSE YOU THINK I SHOULD KNOW? _________________________________________________________________________________________________________________________________________

FULL NAME:_______________________________________________________________________________AGE: _______ DATE OF BIRTH: _______ HEIGHT: _______ GENDER: _________ADDRESS: ________________________________________ EMAIL: ______________________________

________________________________________ PHONE (H:) ____________________ (C:)_________________ BEST CONTACT?_______________

CURRENT WEIGHT : _______ 6-MONTHS AGO? _______ 1-YEAR AGO? _____ARE YOU LOOKING TO: ___ LOSE ___ GAIN ___ MAINTAINHOW MUCH? _______ TIME FRAME? ______

PLEASE LIST YOUR MAIN HEALTH CONCERNS/SYMPTOMS: ____________________________________________________________________________________________________________________________________________________________________________________HOW LONG HAVE YOU EXPERIENCED THESE? __________________________________________________________________________________________ARE THERE ANY FACTORS THAT MAY HAVE/CONTINUE TO PERPETUATE THIS CONDITION? ____________________________________________________________________________________________________________________________________________________________________________________HAVE YOU CONSULTED ANY OF THE FOLLOWING FOR THIS? __ YES / NO ____ MEDICAL DOCTOR __ NATUROPATH __ DIETICIAN __ OTHER PLEASE DESCRIBE THEIR TREATMENT PROTOCOL: ____________________________________________________________________________________________________________________________________________________________________________________HAVE YOU USED/TRIED ANY OF THE FOLLOWING TREATMENTS?__ DIET MODIFICATION __ VITES/SUPPS __ HOMEOPATHY/TCM __ CHIROPRACTOR__ ACUPUNCTURE __ Rx DRUGS __ NATUROPATHY __ ACUPUNCTURE

CURRENT RELATIONSHIP STATUS: _________________________________________________________NAME OF SPOUSE: __________________________ CHILDREN? ______________ AGES?___________ OCCUPATION: ___________________ SHIFT WORK? ______ DO YOU ENJOY WORK? ___________LEVEL OF STRESS: @ HOME (1=LOW-10= HIGH) ________ @ WORK ________MAJOR CAUSES OF STRESS: _________________________________________________________________________________________

HOURS PER DAY SPENT: WORKING: _______ TRAVELING: _______ SITTING: _______ COMPUTER/TV: _______HOW WOULD YOU RATE YOUR HEALTH? __ EXCELLENT __ GOOD __ FAIR __ POOR PLEASE LIST ALL KNOWN FOOD ALLERGIES & SENSITIVITIES

PLEASE LIST ALL PERTINENT/CURRENT SUPPLEMENTS & PRESCRIPTIONS:

HAVE YOU RECENTLY TAKEN ANTIBIOTICS? _______ LENGTH OF USE? _______ WHAT IS YOUR BLOOD TYPE? ___ A ___ B ___ AB ___ O HOW IS/WAS THE HEALTH OF YOUR PARENTS? _________________________________________________________________________________________FAMILY HISTORY OF PARTICULAR DISEASE/SYMPTOM? : _________________________________________________________________________________________

GENERAL ENERGY (1= Low | 10= High) _____ HIGHEST? _____ LOWEST? ______DO YOU SUFFER FROM ANY OF THE FOLLOWING?__ SEASONAL ALLERGIES __ CONSTIPATION __ GALL/KIDNEY STONES__ ANXIETY __ DRY FLAKY SKIN __ GOUT __ LOW LIBIDO__ BAD BREATH/ODOR __ DIARRHEA __ HEADACHES __ POOR MEMORY__ BLOATING/PUFFINESS __ DIFFICULT URINATION __ IRRITABILITY __ WEIGHT LOSS__ COLD HANDS/FEET __ FREQ. URINATION __ JOINT PAIN __ WEIGHT GAIN

HOW MANY TIMES PER DAY DO YOU: SMOKE: _____ DRINK ALCOHOL: _______ DRINK COFFEE: _______HOW OFTEN DO YOU EXERCISE? __ 1-2 DAYS PER WEEK 3-4 DPW 5-7 DPWDURATION & INTENSITY/TYPE OF WORKOUT: ______________________________HOURS OF SLEEP? ________ DIFFICULTY FALLING ASLEEP? ______ STAYING ASLEEP? ________WHAT TIME DO YOU WAKE? _________ GO TO SLEEP? _______

HAVE YOU SUFFERED/BEEN DIAGNOSED FROM ANY OF THE FOLLOWING? (Mark with an ‘X’)__ ALCOHOLISM __ CANCER __ DIABETES I __ FIBROMYALGIA __ HYPO-__ ALZHEIMERS __ HEART DISEASE __ DIABETES II __ HEP A THYROID__ ANEMIA __ CELIACS __ DIGESTIVE ISSUES __ HEP B __ MIGRAINES__ ASTHMA __ FATIGUE __ EMO. EATING __ HEP C __ NEURODE-__ AUTO-IMMUNE __ COLITIS __ ECZEMA __ HIGH BP GENERATIVE __ BRONCHITIS __ DEPRESSION __ EPILEPSY __ HIGH CHOL.__ BILIARY DISEASE __ DEMENTIA __ EBV __ HYPER-THYROID

APPROXIMATE GLASSES/OUNCES WATER PER DAY? _______ IS IT FILTERED? ___________________

DO YOU CATEGORIZE YOURSELF AS FOLLOWING A DIET:__ LOW CARB __ LOW FAT __ GLUTEN FREE __ HIGH CARB __ HIGH PROTEIN__ PALEO __ PESCATARIAN __ RAW __ VEGETARIAN __ VEGANOTHER? ___________________________

RATE THE FREQUENCY YOU USE THE FOLLOWING (1 = LOW | 10= HIGH) __ ARTIFICIAL SWEETENERS __ SALTY JUNK FOOD __ PROTEIN BARS/SHAKES__ BEANS/LEGUMES __ MILK ALTERNATIVES __ REFINED FLOURS__ DAIRY/CHEESE __ NON-STARCHY VEG. __ SWEET SNACKS__ FRUIT __ NUTS/SEEDS ___ STARCHY VEG.__ LEAFY GREENS __ PROCESSED DELI MEATS ___ WHOLE GRAINS

WHAT TIME DO YOU EAT: BREAKFAST _____ LUNCH: ____ DINNER: ____ SNACK(S:) _____________DO YOU PRIMARILY PREPARE or PURCHASE YOUR SNACKS/MEALS? ___________________________________________________________________________________________HOW WOULD YOU RATE YOUR CULINARY KNOWLEDGE/ EXPERIENCE? (1=NOVICE | 10= PRO) _____WHAT ARE WOULD YOU SAY ARE YOUR BIGGEST INHIBITORS FOR EATING HEALTHIER? _______________________________________________MOST OF YOUR MEALS TAKE PLACE: (PLEASE CIRCLE)

RESTAURANT HOME ALONE FAST FOOD CAR/ON THE GO STANDING FAMILY

TYPICAL DAY OF MEALS:• BREAKFAST: _______________________________________________________________________• LUNCH: ___________________________________________________________________________• DINNER: __________________________________________________________________________• SNACKS: __________________________________________________________________________

WHAT ARE YOUR FAVORITE RESTAURANTs or CUISINES?__ AMERICAN/ BURGERS __ DINER/COMFORT __ JAPANESE/ SUSHI __ SOUL FOOD__ BBQ __ FRENCH __ MEXICAN __ SPANISH__ CHINESE __ HEALTHY/ORGANIC __ MEDITERRANEAN __ PUB__ DELI __ ITALIAN __ MIDDLE EASTERN __ VEGAN

PLEASE LIST 2-3 RESTAURANTS WHERE YOU DINE OFTEN: ___________________________________________________________________________________________LIST 2-3 OF YOUR FAVORITE DISHES TO ORDER OUT: ______________________________________________________________________________________________________________________________________________________________________________________LIST 2-3 OF YOUR FAVORITE DISHES TO MAKE AT HOME: ______________________________________________________________________________________________________________________________________________________________________________________FOOD SENSITIVITIES/AVERSIONS/AVOIDANCE? ___________________________________________________________________________________________WHAT FOODS ARE YOU NOT WILLING TO GIVE UP? _____________________________________________DO YOU CRAVE FOODS THAT ARE HIGH IN:__ CHOCOLATE __ CARBS __ FAT __ PROTEIN __ SALT __ SUGAR

DO YOU SUFFER FROM ANY OF ThE FOLLOWING FOOD SENSITIVITIES ? __ EGGS __ FISH __ ONIONS __ PEPPERS __ TOMATOES__ EGGPLANT __ GARLIC __ MUSHROOMS __ SHELLFISH __ TREE NUTS__ DAIRY __ GLUTEN __PEANUTS __ SOY __ WHEATOTHER: _______________________________________ PLEASE CHECK THOSE YOU ENJOY & CROSS OUT THOSE YOU DISLIKE: __ BISON __ FISH __ PORK __ SHELLFISH __ VEAL__ CHICKEN __ GOAT/LAMB __ RED MEAT __ TURKEY __ VEGANPLEASE LIST YOUR FAVORITE TYPES OF FISH/SHELL-FISH:_____________________________________________

DO YOU EAT ANY OF THE FOLLOWING DAIRY PRODUCTS EACH WEEK? ___ EGG WHITES ___ PECORINO ___ GOAT CHEESE ___ MILK ALT.___ EGG YOLKS ___ Other Cheeses?___ GREEK YOGURT ___ 2% MILK ___ FETA CHEESE ___ PARMESAN ___ KEFIRPLEASE LIST THE FOLLOWING:FAVORITE PASTA SAUCE (s:) ________________________________________________________________ FAVORITE SOUP (S:) ________________________________________________________________________ FAVORITE SALAD DRESSING (S:) ____________________________________________________________

PLEASE CHECK ALL VEGETABLES YOU ENJOY EATING:

__ ARTICHOKES __ BRUSSEL SPROUTS __ CORN __ FENNEL __ PEAS__ ASPARAGUS __ CABBAGE __ CUCUMBER __ KALE __ PEPPER__ ARUGULA __ CAULIFLOWER __ DANDELION __ MUSHROOM __ POTATO __ BEETS __ CARROTS __ EGGPLANT __ NORI __ SQUASH __ BROCCOLI __ CELERY __ ESCAROLE __ PALM HEART __ SPINACH __ ZUCCHINIPLEASE CHECK ALL FRUITS YOU ENJOY EATING: __ APPLES __ BLACKBERRIES __ PEACHES __ GRAPES __ NECTARINES __ APRICOTS __ BLUEBERRIES __ PLUMS __ KIWI __ ORANGES __ AVOCADO __ CANTALOUPE __ FIGS __ LYCHEE __ OLIVES __ BANANA __ CHERRIES __ GRAPEFRUIT __ MANGO __ PEARS__ WATERMLN __ CLEMENTINESPLEASE CHECK ALL HERBS/SPICES YOU ENJOY EATING: __ ALLSPICE __ CILANTRO __ COCONUT __ DILL __ JERK __ ONION __ BASIL __ CHILES __ CUMIN __ GARLIC __ LEMON __ ORANGE __ BAY LEAF __ CINNAMON __ CURRY __ GINGER __ NUTMEG __ OREGANO __ THYME __ PARSLEY __ ROSEMARY PLEASE CHECK ALL YOU ENJOY EATING: __ ALMONDS __ BUCKWHEAT __ BLACK EYED __ FARRO __ LENTILS __ PEANUTS __ BARLEY __ BULGUR __ PEAS __ HAZELNUTS __ OATS __ PINE NUTS __ BLACKBEANS __ BRAZIL NUTS __ CHICKPEAS __ KIDNEY BEANS __ PECANS __ WALNUTS __ QUINOA __ SPELT __ WHITE BEANS DO YOU FEEL YOURSELF MINDLESSLY SNACKING DURING THE DAY? YES / NO IF YES, WHAT TIME(S:) ___________________________________________________________________________________DO YOU SUFFER FROM ANY SYMPTOMS BEFORE OR AFTER MEALS? PLEASE SPECIFY...___________________________________________________________________________________________ANYTHING ELSE YOU THINK I SHOULD KNOW? _________________________________________________________________________________________________________________________________________

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