Thank you for taking the time to fill this out and sending it to me prior to your session. All information will be kept confidential.

Your Name

Your Email

1. What is your main health concern?

2. What have you done in the past to work on this? What has proven effective?

3. Do you have trouble sleeping? And how many hours of sleep do you get?

4. What is your current diet like? Please be specific, list breakfast, lunch, dinner and snacks and times you eat.

5. Are you taking any supplements or medications? Please list what you take and what it’s for.

6. Where would you like your health to be 3 months from now? How about 6 months from now?

7. What obstacles, challenges and struggles do you come up with regarding diet/lifestyle?

8. What do you hope to get out of our time together?

9. What are 5 things you LOVE about your life?