Address: City:
State: Zip:
Email:
Phone:
How did you hear about Real Life Food.com?:
Age:
Date of Birth:
Height: Feet Inches
Current weight: Weight one year ago:
Ideal weight:
Blood type:
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Heritage/Ancestry:
History of family health problems:
Relationship Status:
If currently in a relationship, how is your significant other’s health?:
Do you have children?: YES NO
If so, how is their health?:
Occupation:
Please rate your stress levels on a scale of 1-10 (10 being high): Stress Levels: 1 2 3 4 5 6 7 8 9 10
How would you rate the pace of your life: Very fast paced Busy, little free time Moderate Slow, Relaxed Pace: Fast Moderate Relaxed
Do you experience any troubles with digestion?: (constipation, diarrhea, IBS, colitis, acid reflux, etc.) Yes No
If yes, please provide more information:
How do you sleep at night?:
If you wake up during the night, at what times and why?:
What time do you normally go to bed and normally rise?:
Do you have energy upon waking?: Yes No
Do you drink coffee first thing in the morning to wake up?: Yes No
Do you drink any other caffeinated beverages in the morning to wake up?: Yes No
Have you had any recent surgeries or illnesses?: Yes No
If yes, please explain:
Questions for Women:
Do you experience PMS symptoms.: Yes No
If so, please describe:
Is your menstrual cycle irregular?: Yes No
What is your favorite food?:
What is your favorite dessert?:
What is your favorite "health" food?:
What is your least favorite food?:
How many times per week do you eat out?:
Where do you usually eat out?:
How many times do you cook a meal each week?:
How much water do you drink per day?:
Do you eat when you are bored?: Yes No, or stressed Yes No
Do you have challenges with portion control?: Yes No
Are you addicted to any of the following – caffeine, sugar, alcohol, or cigarettes?
If yes, please list:
What typical foods did you eat as a child?:
Please detail the foods you typically eat for:
Breakfast:
Lunch:
Dinner:
Snacks:
Beverages:
How often do you exercise?:
What type of exercise do you do/like best?:
Have you tried health/weight loss programs in the past?: Yes No
If so, which, and were they successful?:
Please list any current medications:
Please list any current vitamins or supplements:
Please list any current therapies you are undertaking (i.e. mental health, massage, or other):
What are your major health concerns?:
What would you like to be different 6 months from now?:
What is holding you back from being healthier?:
Would individualized support help you to reach your goals?: Yes No
Is there anything else that is important to know regarding your health that you have not mentioned?:
