Health Survey Your First Name (required) Your Last Name (required) Your Address Your Email (required) Contact phone number Age Birthdate Height Current weight Weight 6 months ago Weight one year ago Target weight Health Concerns Goals At what point in your life did you feel best? Any serious illnesses/hospitalizations/injuries? How is your sleep Do 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?: Do you cook?: What percentage of your food is home-cooked?: Where do you get the rest from?: Do you crave sugar, coffee, cigarettes, or have any major addictions?: The most important thing I should do to improve my health is:
