Evaluation Personal Information Name (required) Address City State Best Phone # Alternate Phone # Your Email (required) Birthdate Physical Information Height ft in Current Weight (lbs) Max Weight (lbs) Max Weight Year (YYYY) Health Concerns What are your most important health concerns? Describe anything that may have contributed to these concerns Goals What are your Goals? Medical Please describe all hospitalizations and surgeries Please list all current medications and suppliments Risks Do you smoke?NoYes Quantity per day For how many years Exercise Do you current exercise?NoYes If so, describe (type, duration, frequency) Sleep How many hours of sleep to you get per night? Do you fall asleep easily?NoYes Do you wake often during the night?NoYes Do you wake up feeling rested?NoYes Medical History Indicate if you or a family member has had any of the the follow (now or in the past) Disease Self Family Alcoholism Self Family Anemia Self Family Anorexia Self Family Arthritis Self Family Asthma Self Family Binge Eating Self Family Bulimia Self Family Cancer Self Family Compulsive overeating Self Family Crohn's disease/colitis Self Family Depression Self Family Diabetes Self Family Food Allergies or Sensitivities Self Family Heart Disease Self Family Hepatitis Self Family Herpes Self Family High Blood Pressure Self Family Low Blood Pressure Self Family High Cholesterol Self Family HIV Self Family Hypoglycemia Self Family Irritable bowel syndrome Self Family Kidney disease Self Family Lupus Self Family Lyme disease Self Family Mental illness Self Family Migraine Headaches Self Family Multiple Sclerosis Self Family Stomach/Intestinal Ulcers Self Family Stroke Self Family Substance Abuse Self Family Thyroid disease Self Family Δ