Client Questionnaire

Please fill out the below to the best of your ability / knowledge.

Name *
What is the best number to reach you? *
What is the best number to reach you?
For correspondence and fun surprises!
Date of Birth *
Date of Birth
What is the lowest adult weight you remember? Highest? Weight you felt the best at?
How often? For work or pleasure? Internationally or domestic? Do you have trouble making healthy choices?
Current / Past Lifestyle Choices *
Please check all that apply.
Current Diet / Food Choices *
Please list breakfast, lunch, dinner, and snacks.
Fast? Slow? In front of the television or computer? In transit?
1 glass = 8 ounces
1 serving = 1 cup raw or 1/2 cup cooked
How often do your weaknesses affect your diet?
Are you tired in the afternoon? Do you need coffee to wake-up in the morning?
When is bedtime? Do you wake during the night? Can you easily fall back asleep? What time do you wake-up? Do you require an alarm or do you wake-up naturally?
1 = as low stress as it gets and 10 = as stressed as possible. What is the cause of stress? Family? Work? Health?
Are you currently seeking professional treatment?
If yes, please describe.
1 = everything is always in its place and 10 = always in disaster mode. What does your desk look like? Bedroom? Refrigerator?
What is the length of your cycle? Heavy? Light? Or, are you currently experiencing / past menopause?
Were you in the past?
Gas? Bloating? Constipation? Diarrhea? Do you take anything to help your bowels?