(Filling out the form below will help me best prepare for your appointment.)

Name

First Name

Last Name

Phone Number

(###)

###

####

Age

What is your main health concern?

What have you done in the past to work on this health condition (include both alternative & traditional modalities)?

What has proven effective?

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

What would you like your health to be 30 days from now? How about 90 days from now? How would you feel if you got this result?

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

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

Are you willing and able to invest in your health and well-being?

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

What are 5 things you LOVE about your life?