Personal informationAll your information will be kept confidential between you and the Health Consultant.First NameField is required!Field is required!Last nameField is required!Field is required!AgeField is required!Field is required!HeightField is required!Field is required!Date of birthSelecione FechaField is required!Field is required!Place of birthField is required!Field is required!EmailField is required!Field is required!How often do you check your email?DailyWeeklyHardly everField is required!Field is required!Home phone:Phone NumberField is required!Field is required!JobField is required!Field is required!Cell phoneField is required!Field is required!Actual weight:Field is required!Field is required!Weight 6 months ago:Field is required!Field is required!Weight a year ago:Field is required!Field is required!Would you like your weight to be different?Field is required!Field is required!If so, how much?Field is required!Field is required!SocialMarital status:Field is required!Field is required!Where you live now?Field is required!Field is required!Sons?Field is required!Field is required!Pets?Field is required!Field is required!Profession:Field is required!Field is required!Working hours per week:Field is required!Field is required!HEALTHPlease list your top health concerns:Field is required!Field is required!Other concerns and / or goals?Field is required!Field is required!At what stage of your life have you felt better?Field is required!Field is required!Have you had a serious illness, hospitalization, or injury?Field is required!Field is required!How is / was your mother's health?Field is required!Field is required!How is / was your father's health?Field is required!Field is required!How is / was your father's health?Field is required!Field is required!What is your ethnic background?Field is required!Field is required!What is your blood group?Field is required!Field is required!How do you sleep?Field is required!Field is required!How many hours?Field is required!Field is required!Do you wake up during the night?Field is required!Field is required!Why?Field is required!Field is required!Any pain, stiffness, swelling?Field is required!Field is required!Constipation / diarrhea / gas?Field is required!Field is required!Allergies or sensitivity? Please explain:Field is required!Field is required!WOMEN'S HEALTHIs your menstruation regular?Field is required!Field is required!How many days does it last?Field is required!Field is required!How often?Field is required!Field is required!Do you have pain or symptoms? Please explain:Field is required!Field is required!Are you having or are you close to menopause? Please explain:Field is required!Field is required!Birth control history:Field is required!Field is required!Do you get yeast or urinary tract infections? Please explain:Field is required!Field is required!MEDICALDo you take any supplements or medications? Please make a list:Field is required!Field is required!What role do sports and exercise play in your life?Field is required!Field is required!Any healer, helper, or therapy you are involved with? Please indicate them:Field is required!Field is required!FOODDid your family and / or friends support you in your desire to make changes in your eating and / or lifestyle?Field is required!Field is required!You cook?YESNOField is required!Field is required!What percentage of your food is homemade?Field is required!Field is required!Where do you get the rest?Field is required!Field is required!Do you get cravings for sugar, coffee, cigarettes, or do you have a strong addiction?Field is required!Field is required!What foods to eat frequently as a child?BreakfastField is required!Field is required!LunchField is required!Field is required!DinnerField is required!Field is required!SnacksField is required!Field is required!LiquidsField is required!Field is required!What kinds of foods do you eat today?BreakfastField is required!Field is required!LunchField is required!Field is required!DinnerField is required!Field is required!SnacksField is required!Field is required!LiquidsField is required!Field is required!ADDITIONAL COMMENTSIs there anything else you would like to share?Field is required!Field is required!Submit
