Full Name

Address

City

State

Zip Code

Email Address	Daytime Phone	Evening Phone	Cell Phone
Age	Height	Date of Birth	Place of Birth

Current weight

Six months ago?

One year ago?

Would you like your weight to be different? Yes No
If Yes, please explain

Relationship status Children?

Occupation: How many hours a week do you work?

Do you sleep well? Yes No   Do you wake up at nights? Yes No   What time(s)?

To urinate:   What time do you generally get up in the morning?

Do you experience constipation/diarrhea? Yes No
If yes, please explain

What blood type are you?   What is your ancestry?

Women:
Are your periods regular? Yes No
How many days is your flow?   How frequent?

Painful or symptomatic? Yes No
Please explain