Never miss another delicious, easy recipe or health tip Sign up to my newsletter! Health Clarity Questionnaire First Name:*Last Name*Email* Email: How often do you check email?*Phone: HomePhone: MobilePhone: WorkTell Me About YourselfAge:Height:Birthdate:Place of Birth:Current weightWeight six months ago:One year ago:Would you like your weight to be different? If so, what?Social InformationRelationship StatusSingleMarriedDivorcedPartneredSeparatedWhere do you currently live?Children:Pets:Occupation:Hours of work per week:HEALTH INFORMATION:Please list your main health concerns:Other concerns and/or goals?At what point in your life did you feel best?Any serious illnesses/hospitalizations/injuries?How is/was the health of your mother?How is/was the health of your father?What is your ancestry?What blood type are you?A (+)A (-)B (+)B (-)O (+)O (-)AB (+)AB (-)How is your sleep? How many hours?Do you wake up at night?YesNoWhy?Any pain, stiffness, or swelling?Do You Have Constipation Diarrhea Gas Allergies or sensitivities? Please explain:For The LadiesAre your periods regular?How many days is your flow?How frequent?Painful or symptomatic? Please explain:Reached or approaching menopause? Please explain:Birth control history:Do you experience yeast infections or urinary tract infections? Please explain:MEDICAL INFORMATIONDo you take any supplements or medications? Please list:Any healers, helpers, or therapies with which you are involved? Please list:What role do sports and exercise play in your life?FOOD INFORMATIONWhat foods did you eat often as a child?BreakfastLunchDinnerSnacksLiquidsWill family and/or friends be supportive of your desire to make food and/or lifestyle changes?Do you cook?What percentage of your food is home-cooked?Where do you get the rest from?Do You Crave: Sugar Coffee/Caffeine Cigarettes Do you have any other major addictions?The most important thing I should do to improve my health is:ADDITIONAL COMMENTSIs there anything else you would like to share?CommentsThis field is for validation purposes and should be left unchanged.
