Initial Health Questionnaire

Name*
First Last
Email*
Phone*
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Mainly for phone/Zoom clients if I need to post referrals or supplements
Date of Birth*
Date Format: DD slash MM slash YYYY
Male/Female*
- Male
- Female
Height in cm
Needed for face to face clients to program the scales.
Occupation
It's relevant to find out if you have a desk job, or you are on your feet all day. If you do shift work. If you are exposed to environmental toxins etc.
Household / Family situation*
It's relevant to understand if you are preparing your own food, feeding a family, someone else in your household cooks for you.
If under 18, what's your guardian's name?
If someone referred you to us, who was it?

Please list your main health concerns in order of decreasing severity (starting with the worst one)*
On a scale of 1 to 10 (10 being the most important), how important is it to you to resolve these issues in the next 3 to 6 months?
Who or what do you think is your biggest obstacle to achieving your health goals?
What other methods, diets etc have you tried? What didn't work for you and why?
Do you have any other commitments that would keep you from being 100% successful in accomplishing your goals?

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