New Client Questionnaire First Name* Last Name* Age*Date of Birth* Month Day Year Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Cell PhoneWork PhoneGenetic Background* African American Hispanic Mediterranean Asian Native American Caucasian Northern European Other Other Genetic Background* General Health InformationPlease list the most important health concern you wish to work on during the free trial and why.*When was the last time you felt well?*Did something trigger your change in health?*What makes you feel better?*What makes you feel worse?*How does your condition affect you?*What do you think is happening and why?*What do you feel needs to happen for you to get better?*SleepHow many hours of sleep do you get each night on average?* Do you have problems falling asleep?* Yes No Staying asleep?* Yes No Do you have problems with insomnia?* Yes No Do you snore?* Yes No Do you feel rested upon awakening?* Yes No Do you use sleeping aids?* Yes No What kind of sleeping aids do you use?* ExerciseCurrent Exercise ProgramAdd rows as needed using the plus sign on the right.Activity# of Times Per WeekDuration (Minutes) Do you feel motivated to exercise?* Yes A little No Are there any problems that limit exercise?* Yes No What problems limit exercise?* Do you feel unusually fatigued or sore after exercise?* Yes A little No Explain your feelings after exercise:* NutritionCheck the factors that apply to your current lifestyle and eating habits: Fast eater Eat too much Late-night eating Dislike healthy foods Time constraints Travel frequently Eat more than 50% of meals away from home Healthy foods not readily available Poor snack choices Significant other or family members don’t like healthy foods Significant other or family members have special dietary needs Love to eat Eat because I have to Have negative relationship to food Struggle with eating issues Emotional eater (eat when sad, lonely, bored, etc.) Eat too much under stress Eat too little under stress Don’t care to cook Confused about nutritional advice StressDo you feel you have an excessive amount of stress in your life?* Yes No Do you feel you can easily handle the stress in your life?* Yes No What are your hobbies or leisure activities?*How Well Have Things Been Going for You?How well are things going overall?*On a scale of 1 (poorly) to 5 (very well) 1 2 3 4 5 6 7 8 9 10 N/A How well are things going at school?*On a scale of 1 (poorly) to 5 (very well) 1 2 3 4 5 6 7 8 9 10 N/A How well are things going in your job?*On a scale of 1 (poorly) to 5 (very well) 1 2 3 4 5 6 7 8 9 10 N/A How well are things going in your social life?*On a scale of 1 (poorly) to 5 (very well) 1 2 3 4 5 6 7 8 9 10 N/A How well are things going with your close friends?*On a scale of 1 (poorly) to 5 (very well) 1 2 3 4 5 6 7 8 9 10 N/A How well are things going with sex?*On a scale of 1 (poorly) to 5 (very well) 1 2 3 4 5 6 7 8 9 10 N/A How well are things going with your attitude?*On a scale of 1 (poorly) to 5 (very well) 1 2 3 4 5 6 7 8 9 10 N/A How well are things going with your boyfriend/girlfriend?*On a scale of 1 (poorly) to 5 (very well) 1 2 3 4 5 6 7 8 9 10 N/A How well are things going with your children?*On a scale of 1 (poorly) to 5 (very well) 1 2 3 4 5 6 7 8 9 10 N/A How well are things going with your parents?*On a scale of 1 (poorly) to 5 (very well) 1 2 3 4 5 6 7 8 9 10 N/A How well are things going with your spouse?*On a scale of 1 (poorly) to 5 (very well) 1 2 3 4 5 6 7 8 9 10 N/A Current Medications & SupplementsCurrent Medications (prescriptions and over-the-counter)Add rows as needed using the plus sign on the right.MedicationDosageStart Date MM/YYReason for Use Nutritional Supplements (vitamins, minerals and herbs)Add rows as needed using the plus sign on the right.Name and BrandDosageStart Date MM/YYReason for Use Readiness Assessment & Health GoalsAre you willing to significantly modify my diet?*On a scale of 1 (not willing) to 5 (very willing) 1 2 3 4 5 Are you willing to take several nutritional supplements each day?*On a scale of 1 (not willing) to 5 (very willing) 1 2 3 4 5 Are you willing to keep a record of everything you eat each day?*On a scale of 1 (not willing) to 5 (very willing) 1 2 3 4 5 Are you willing to modify your lifestyle (work, demands, sleep habits, etc.)*On a scale of 1 (not willing) to 5 (very willing) 1 2 3 4 5 Are you willing to practice a relaxation technique?*On a scale of 1 (not willing) to 5 (very willing) 1 2 3 4 5 Are you willing to engage in regular exercise?*On a scale of 1 (not willing) to 5 (very willing) 1 2 3 4 5 How confident are you of your ability to organize and follow through on above health-related activities?*On a scale of 1 (not confident) to 5 (very confident) 1 2 3 4 5 What aspects of yourself or your life lead you to question your ability to follow through?* At the present time, how supportive do you think the people in your household will be to your implementing the above changes?*On a scale of 1 (not supportive) to 5 (very supportive) 1 2 3 4 5 How much ongoing support (phone consults, email correspondence, etc.) from our professional staff would be helpful to you as you implement your personal health program?*On a scale of 1 (very infrequent contact) to 5 (very frequent contact) 1 2 3 4 5 CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
