Name

Email Address

Tell me a bit about yourself. What's your family like? What do you do for work and fun?

Which of these sound like you? (Check all that apply) Which of these sound like you? (Check all that apply) I'm a perfectionist I'm a natural leader, I was considered bossy as a child I'm the life of the party, but I sometimes forget to listen to other people I'm attracted to beautiful things, I notice design I prefer to go-with-the-flow, I have a hard time with structure I'm very compassionate, empathetic, and nurturing I have a few very close friends, and less acquaintances than other people might have I like to figure things out and get into the details I have a firey personality I am generally pretty content I am very creative

Do you have any chronic health conditions?

Where do you live? What's the weather like throughout the year? What's your favorite weather? What kind of weather drags you down the most?

What are your goals? What are you hoping to achieve with this plan?

What have you tried to do for this in the past?

What are your biggest challenges right now? What might get in the way of your success?

What does your diet currently look like? What do you have for breakfast, lunch, and dinner? (Please give at least 2 examples of each).

When do you eat? Where do you eat? Who do you eat with?

What do you drink throughout the day?

Do you drink alcohol? If so, how much?

What does your typical day and week look like? Please go into as much detail as possible, especially when it comes to daily routines.

Do you have any allergies or food aversions?

Do you have a history of dieting, yo-yo dieting, cleansing, detoxing, or eating disorders? If so, please explain.

How's your sleep? When do you go to bed? When do you get out of bed? Do you have trouble falling asleep? Do you wake in the night? Do you go to the bathroom at night (if so, how often?) How do you feel when you have insomnia (if you have insomnia)?

What's your energy level like? Do you have a "dip" at any point in the day? Do you do anything to help you keep your energy up? Is there a time of year where you notice that you have more or less energy? How do you feel first thing in the morning?

Check all of the following that apply: Check all of the following that apply: I often feel hot My skin is generally rosy I have skin conditions like acne, rashes, eczema, psoriasis, etc. I experience acid reflux I often have strong body odor and/or bad breath When I get sick, I usually have intense flare-ups that don't last too long I have a large appetite

Check all of the following that apply: Check all of the following that apply: I have a loud voice I have angry outbursts I am generally extroverted

Check all of the following that apply: Check all of the following that apply: I often feel cold I have poor circulation I often feel tired My body is often achey, I experience dull pains I crave warm beverages I have a low appetite I have chronic health conditions, when I get sick I usually have lingering symptoms for a long time

Check all of the following that apply: Check all of the following that apply: I have a quiet voice I prefer small groups to large crowds I am generally introverted

Check all of the following that apply: Check all of the following that apply: I am more thirsty than most I experience dry skin I experience dry lips My hair is coarse and brittle I tend toward hypoglycemia I experience cracking or popping joints I frequently experience gassiness

Check all of the following that apply: Check all of the following that apply: I have a strong work ethic I experience anxiety I tend to be stuck in my ways, some might call me inflexible

Check all of the following that apply: Check all of the following that apply: I have trouble getting up in the morning I sweat more than others I experience a heavy feeling in my body I often have a foggy-brain feeling I experience frequent nausea If I sleep too much or take a nap, I just end up feeling sleepier I experience frequent bloating

Check all of the following that apply: Check all of the following that apply: I'm indecisive, spontaneous, some might call me flaky I worry and ruminate a lot I am more emotional/teary than others

It's not the most pleasant of topics, but your bowel movements can reveal a lot about imbalances in your body. I know it's a stinky topic, but please hold your nose and check all of the following that apply. It's not the most pleasant of topics, but your bowel movements can reveal a lot about imbalances in your body. I know it's a stinky topic, but please hold your nose and check all of the following that apply. I usually have 1-2 bowel movements a day I usually have a bowel movement every other day I usually have less than three bowel movements a week I usually have 3 or more bowel movements a day I often have burning sensations with my bowel movements My bowel movements are often very sticky I often see mucous in my bowel movements My bowel movements are often hard and dry I often have to strain on the toilet My bowel movements usually feel incomplete My bowel movements are well formed My bowel movements are usually quite loose I frequently have diarrhea I frequently feel constipated

Your menstrual cycle is another thing that can tell me a lot about your overall health and what your body needs in order to thrive. Please describe your menstrual cycle (check all that apply) Your menstrual cycle is another thing that can tell me a lot about your overall health and what your body needs in order to thrive. Please describe your menstrual cycle (check all that apply) I have irregular periods My cycle is usually less than 21 days long My cycle is usually between 21-28 days long My cycle is usually longer than 28 days I often skip a month or more My period lasts less than 3 days My period lasts between 3-5 days My period lasts more than 5 days I experience clots that are smaller than a dime I experience clots that are between the size of a dime and a quarter I experience clots that are larger than a quarter I experience cramping in my lower abdomen I experience cramping in my lower back I experience cramping before my period I experience cramping during my period I experience cramping after my period My blood is bright red My blood is brown My blood is dark red My blood is purple I experience spotting right before my period I experience spotting at the end of my period I experience spotting in the middle of my cycle I am currently on hormonal birth control or have an IUD I have been on birth control in the past

Is there anything else you'd like to share with me?