Name

First Name

Last Name

Phone

(###)

###

####

Email Address

Birthdate

YYYY

Where do you currently live?

How many hours a week do you typically work?

What is your stress level at?

Please list your main health concerns.

List your main health/wellness goals.

Do you have any serious illnesses?

Are you currently taking any supplements and/or medications?

Are there any healers or therapies you’re currently involved with?

How many hours do you normally sleep?

What role do exercise and/or sports play in your life?

What do you typically eat for breakfast?

For lunch?

For Dinner?

What are your usual snacks, if any, throughout the day?

What liquids do you consume throughout the day?

How often do you cook at home?

Any food allergies?

What do you do in your down time?

Do you take any time for yourself to relax? If so, what does that look like for you?

Do you have any religious beliefs or a spiritual practice?

What brand of beauty products and household cleaning products do you use?

Is there anything else you would like me to know about you?

Consultation Form