• CLIENT ONBOARDING

    Personal Information
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Genetic Background*
  • Relationship Status*
  • How many hours of work per week?*

  • HEALTH INFORMATION

  • What blood Type are you?*
  • When do you feel the most tired?
  • How often do you feel sad, depressed or unhappy?
  • How is your elimination?
  • Please select if you suffer with any of these symptoms*

  • Food Information

  • Please select what is your current diet*
  • When do you feel the most hungry?
  • What do you snack on?
  • Do you have a sweet tooth (crave sweets)?
  • How much water do you drink a day?
  • How many times a week do you eat out?
  • How many times a week do you eat bread, bagels, cereal, pasta or baked goods?
  • How many times a week do you eat vegetables?
  • How many times a week do you eat fruits?
  • Do you drink Soda / Energy Drinks or any other fizzy drinks?
  • How often do you eat fast food?
  • Do you drink Coffee?
  • Please select what of the following Lifestyle habits may apply to you*
  • Please select what of the following eating habits may apply to you*

  • Women's Health

  • How long is your flow?
  • Are you currently on any birth control?

  • Reflection

  • PHYSICAL ACTIVITY

  • Please indicate the type of exercise you are currently engaging in.*
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  • WHEEL OF LIFE

    Rate on a scale of 1 (not) to 10 (highly) how satisfied are you with the following:
  •

  • LIFESTYLE 

  • How many hours of sleep do you get a night?
  • In order to improve your health, how willing are you to:(Rate on scale of 5-very willing to 1-not willing)
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