Please answer these 
Biological Sex
Current weight
Measurements in inches
Bust (across nipples)
Waist (across belly button)
Hips (across top of hip bones)
Upper Arm (halfway between shoulder and elbow)
Thigh (halfway between hip and knee)
What is your primary wellness goal?
Will you track your results via testing methods (bloodwork, insulin, etc.)? Explain
Do you consume caffeine? (Coffee, tea, soda, energy drinks)? List which and how much per day.
Do you consume alcohol? List how much per day.
Do you take medication? List which and the condition being treated.
What are your normal breakfast foods?
What are your normal lunch foods?
What are your normal dinner foods?
What are your normal snack foods, if you eat snacks?
What are your normal dessert foods, if you eat desserts?
Rate these: 1 = poor 10 = ideal
Energy Level (1-10)
Physical comfort (lack of pain) (1-10)
Mood (1-10)
Body Image (how you like your body) (1-10)
Joint Mobility (1-10)
Skin Appearance (1-10)
Immune System Function (1-10)
Mental Acuity/Focus (1-10)
Digestion/Regularity (1-10)
Quality of Sleep (1-10)
Overall Wellness (1-10)
Patience (1-10)
Ability to Handle Stress (1-10)
Do you have any other comments or concerns?