Please take a few moments to complete the form below.

This information is extremely important to help me prepare for our initial consultation, and to get the most out of our time together.

Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Occupation

Tell me in a few words what you are looking to achieve with your health and well-being:

GENERAL OVERVIEW: explain your current health situation. Please include duration of pathology or illness, as well as any operations and treatments:

SUPPLEMENTATION & MEDICATION:

Please list any supplements and/or medication you are currently taking and/or used in the past year. Please include the brand and dose.

On a scale of 1-10, how would you describe your energy levels?

1=low energy, 10=full of energy

What is your best time of the day?

How is your sleep?

do you have any issues with sleep, getting to sleep? Staying asleep?

DIET: What do you eat in a typical day for Breakfast?

Lunch:

Dinner:

What do you like to snack on?

Do you have cravings for any particular foods?