Personal information Your First Name * Your Last Name * Your Email * How often do you check your phone (eg for email etc)? * Phone Mobile: * WApp: * Age: * Date of Birth: * Place of Birth: * Current place you live: * Current Weight: * Height: * If you have a current weight target, please specify: * Social information Relationship status: * Children: * Pets: * Occupation: * Hours of work per week: * Health information Please list your main health concerns: * Any other concerns and/or goals? * At what point in your life did you feel your best? * Any serious illnesses/ hospitalisations/ injuries? * How is/was the health of your mother? * How is/was the health of your father? * What is your ancestry? * Which blood type are you? * How is your sleep (/10)? * How many hours? * If you wake up at night; for what reason? * How is your energy (/10)? * Any chest pain or shortness of breath? * Any headaches? * Any problems with your eyesight, smell, taste or hearing? * Any pain, stiffness, or swelling? * Any reflux? * Constipation/ diarrhea/ gas? * How is your flow when you go to the bathroom? * Allergies or sensitivities? Please explain: * For women Are your periods regular? 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 you’re experiencing? Please list: * What role do sports and exercise play in your life? Please give details of any exercise you do: * Food information Which foods did you eat often as a child? Breakfast: * Lunch: * Dinner: * Snacks: * Liquids: * Please summarise your meals etc from yesterday: Breakfast: * Lunch: * Dinner: * Snacks: * Liquids: * Are your family and/or friends supportive of your desire to help your health incl any lifestyle changes? * Do you prepare your own food, if yes - what percentage of your food is home-prepared? * Where do you source the rest of your food from? * Do you crave sugar, coffee, cigarettes, alcohol etc or have any major addictions? * How much plain filtered water do you drink each day? * The most important thing I need to do to improve my health is: * Additional comments Anything else you’d like to share?