Name DOB Gender MaleFemaleOthers Mobile Occupation Email Height (cm/ft) Current Weight (kg/lbs) Hip Measurement (optional) (cm/inches) BMI (if known) Breakfast Lunch Dinner Snacks Drinks (e.g., water, tea, coffee, alcohol) Fresh Fruit Daily2-3 times/weekOccasionallyNever Vegetables Daily2-3 times/weekOccasionallyNever Whole grains (brown rice, oats) Daily2-3 times/weekOccasionallyNever Dairy (milk, yogurt, cheese) Daily2-3 times/weekOccasionallyNever Lean proteins (fish, chicken) Daily2-3 times/weekOccasionallyNever Processed/packaged foods Daily2-3 times/weekOccasionallyNever Sugary foods/drinks (soda, sweets) Daily2-3 times/weekOccasionallyNever Fried foods Daily2-3 times/weekOccasionallyNever Are you currently experiencing any health concerns or symptoms? YesNoOthers Are you taking any medications, supplements, or vitamins? YesNoOthers Is there a history of health issues (e.g., heart disease, diabetes) in your family? YesNoOthers Let’s get real about digestion! How often do you have a bowel movement? Multiple times a dayOnce a dayEvery other dayLess than 3 times a week How would you describe your bowel movements? Regular and easySometimes irregular or hard to passOften uncomfortable or painful On a scale of 1 to 10, how would you rate your current stress level? 12345678910 What are your biggest sources of stress right now? WorkFamily or relationshipHealth concernsFinancial worries How do you usually cope with stress? ExerciseMeditation or mindfulnessEating comfort foodsWatching TV or moviesTalking to friends or family What are your top three health or wellness goals? What is motivating you to make changes to your health now? Want to feel betterImprove my energy levelsManage stressImprove my weight Is there anything else you’d like to share about your diet, lifestyle, or health journey?
