Insight into you Let me know you are This form will take roughly 5 - 10 minutes to complete. It maybe quite vigorous but it will help me understand totally where you are at and allow me to design a plan perfect for you. Please answer the questions as accurately as possible. Step 1 of 9 - Personal Details 11% NameFirstLastGenderMaleFemaleAddressStreet AddressCityState / Province / RegionZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountryAgeUnder 1818-2425-3435-4445-5455-6465 or AbovePrefer Not to Answer EmailContact Phone Number HeightWeight 6 Months agoWeight 12 Months agoCurrent Weight (estimated if unknown)Desired Weight Relationship StatusSingleIn a relationshipMarriedDivorcedWidowedEmployment statusEmployed Full-TimeEmployed Part-TimeSelf-employedNot employedbut looking for workNot employed and not looking for workHomemakerRetiredStudentPrefer Not to Answer Please list your main health concerns:What are your goals with your Health?At what point in your life did you feel best?:Under 1818-2425-3435-4445-5455-6465 or AbovePrefer Not to AnswerWhy do you think that was?Any serious illnesses/hospitalizations/injuries?:YesNoWhat are/were your injuries?*Any known family health issues?YesNoWhat are/were the health issues?What ethnicity are you?NZ EuropeanMixed European-MaoriMaoriAsianPacificOtherMixed (excluding European-Māori)What is your blood type?ABABOUnsureDo you sleep well?Strongly AgreeAgreeDisagreeStrongly DisagreeHow many hours would you sleep before waking in the night?Less than a hour1-2 hours3-6 hoursWhy do you think you don't sleep well?Any pain, stiffness or swelling?:YesNoWhere?*Constipation/Diarrhea/Gas?:YesNoAllergies or sensitivities?YesNoPlease explain: Are your periods regular?YesNoHow many days is your flow?1 - 3 days3 - 5 days5 - 7 days7+ daysHow frequent?Monthly or lessMore than monthlyIs it painful or symptomatic?YesNoUncomfortable but managableIf yes please explain?Reached or approaching menopause?YesNoUnsureIf yes please explain?Please explain your Birth Control historyDo you experience yeast infections or urinary tract infections?YesNoUnsureIf yes please explain? Please list if you take any supplements or medications?Please list healers, helpers or therapies with which you are involved?What role do sports and exercise play in your life? What foods did you eat often as a child?Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?YesNoDo you cook?YesNoHow often would you cook in a normal week?Once a week2 to 3 times a week3 to 6 times a weekEvery nightNeverWhat do you normally eat for the nights you dont eat?* Do you crave sugar, coffee, cigarettes, or have any major addictions?YesNoHow satisfied are you with your diet at the moment?Very SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedAny other helpful information?