Name *
Name
Address *
Address
Birthdate *
Birthdate
What do you do for fun? To relax? Anything outside of work!
This does not need to be limited to diet or weight! Tired? Experience mood swings? Looking to increase strength and endurance?
Share what you need from me to feel successful or feel like you're moving forward towards addressing your health concerns
E.g. "Love it! I crossfit four days per week!" "I don't have time or energy for the gym" "I enjoy moving outside, like hiking, boating, or running with the dog."
If so, what time? *
If so, what time?
What time do you go to bed? *
What time do you go to bed?
What time do you wake up in the morning? *
What time do you wake up in the morning?
E.g. energized, groggy, wanting more sleep, etc.
Do you drink caffeinated beverages? *
E.g. I drink 16oz black coffee twice per day or I drink a 12oz latte once a week.
Do you smoke? *
Cigarettes, hookah, marijuana, etc.
E.g. I smoke a cigarette once a week at the bar or I smoke weed every night before bed.
E.g. A glass of wine with dinner each night, 3-4 cocktails on friday and saturday nights.
Diet or regular
E.g. I have a diet coke once a month, or I drink a soda with every meal.
If you don't know, give a good estimate! Please enter a numerical value only!
Please include brand name and dosage and how long you've been using.
If none, simply type "none".
Please include examples of typical meals or habits.
Please include examples of typical meals or habits.
Please enter a numerical value only. E.g. Enter "70" if 70% of your food is made at home.
Do you crave sugar or carbs? *
E.g. mid-afternoon crave for chocolate or chips.
Do you crave salty foods? *
Are there specific foods that prompt this?
E.g. everyday; only with certain foods, etc.
Do you feel excessively hungry? *
Do you have a poor appetite? *
Family Healthy History *
Please check all that have occurred in your family.
Women Only
Are your periods regular?
E.g. Mild bloating, severe fatigue, irritability.
What the start date of your last period?
What the start date of your last period?
Are you menopausal or peri-menopausal?
Men Only
Do you feel your libido is adequate?
E.g. I used to really love to play disc golf, but now I don't have the energy or drive.