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17

Aug

Intake Women Display

Your responses from August 17, 2012 at 5:00 pm

Personal and Goals

Age28
Heightbnjkl
Date of BirthAugust 2, 2012
Place of Birthbhj
Current Weight26
Weight 6 Months Ago13
Weight 1 Year Ago13
Would you like your weight to be different?No
Relationship StatusSingle
Childrennjk
Petsnjk
Occupationnjklnjkl
Hours of work per week4
Do you know your purpose?

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State your purpose

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Do you live your purpose?

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What are your primary sources of community?

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What are your main health concerns?

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Will family and/or friends be supportive of your desire to make lifestyle changes?

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Any other information or concerns?

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Health History

At what point in your life did you feel the best?

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Any serious illness/hospitalizations/injuries?

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How is the health of your father?

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How is the health of your mother?

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What is your ancestry?mnkl
Do you sleep well?nklkl
How many hours?6
Do you wake up at night?mkl;mkl
Why?njknjk
Any pain, stiffness or swelling?njknjkl
Constipation / Diarrhea / Gas? Please explain:

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Allergies or sensitivities? Please explain:

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Do you take any medications or supplements?

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Any healers, helpers or therapies with which you are involved? Please list:

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What role do sports and exercise play in your life?

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Reproductive Health

Are your periods regular?[pohl1u]
How many days is your flow?[id6ye4]
How frequent?[rlohk7]
Painful or symptomatic? Please explain:[m76hx]
Reached or approaching menopause? Please explain:[ajwwdo]
Birth Control History:[g5w84b]
Do you experience yeast infections or urinary tract infections? Please explain:[fj8eos]

Food

Breakfast

klmkl;
nklnklnkl
nmklnmkl


Lunch

klmkl;
nklnklnkl
nmklnmkl


Dinner

klmkl;
nklnklnkl
nmklnmkl


Snacks

klmkl;
nklnklnkl
nmklnmkl


Liquids

klmkl;
nklnklnkl
nmklnmkl

Do you crave sugar, coffee, cigarettes or have any addictions?

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What percentage of your food is home cooked?22
Where do you get the rest from?njknjkl
Do you cook?njklnjkl
The most important thing I should change about my diet to improve my health is…

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Finish Up

What role, if any, does spirituality play in your life?

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What goals do you have for the next year?

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What are some life goals? (think big)

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Is there anything else you’d like to share?

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