What is the name and type of practitioner? When did you see them? What were the results? Why did you continue or discontinue? Please describe.

For example, are you willing to keep a daily food journal?

Please name which programs or eating styles you have tried and the results you have achieved. For example: lost weight, medical changes, sleep, energy, mental clarity, cravings, or other.

What are you able to do more of / who are you able to be? - Example would be; more patient, more clear, more energetic, better sleep, fewer cravings, etc.

Please use the + button to add rows as needed for each additional child. Type N/A into the first box if not applicable.

Please list your known Medical Conditions (e.g., high blood pressure, diabetes, elevated blood sugar, cholesterol, high LDL, low HDL, elevated liver enzymes, cancer, food allergies or sensitivities etc.) and the year they started. Use the + button to add additional rows as needed — This information will be kept confidential!

Please list Medications you are taking, the dose, how often and what you are taking them for. Please use the + button to add rows as needed for each additional Medication. Type N/A into the first box if not applicable.

Please list what Supplements you are taking, the amounts, how often and what you are taking them for. Please use the + button to add rows as needed for each additional Supplement. Type N/A into the first box if not applicable.

Describe how you normally eat. Check the boxes for all that apply.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Use a scale of 0-10 where 0 = "no progress" and 10 = "achieved ideal outcome". Use N/A if Not Applicable.

Select the best choice that reflects your current feeling on this.

Insert N/A if not applicable.

Use a scale of 0-10 where 0 = "not at all" and 10 = "very important".

Use a scale of 0-10 where 0 = "not at all" and 10 = "very important".

Use a scale of 0-10 where 0 = "not at all" and 10 = "very important".

Use a scale of 0-10 where 0 = "not at all" and 10 = "very important".

Insert N/A if not applicable or unknown.

Insert N/A if not applicable or unknown.

Insert N/A if not applicable or unknown.

Insert N/A if not applicable or unknown.

Insert N/A if not applicable or unknown.

Please list the topics you feel you need more health / wellness information about. One topic per line. Click the + button to add additional lines for each additional topic.