Short form: Contact InformationName* First Last Email* PhoneHealth concerns and goalsWhat are your health concerns?check all that apply weight loss healthy eating low energy digestive issues lifestyle change high blood pressure high cholesterol disease prevention skin issues depression anxiety bloating headaches migraines underweight eating disorder Other What is your weight goal?* If you are not concerned about weight and would like to focus solely on health then please skip down to food section. FoodWhat do you typically eat and drink?Give me a general idea of your eating habitsDo have a special diet (vegan, vegetarian, etc?)No, I eat a variety of foodsYes, I'm vegetarianYes, I'm veganYes, I'm a PescatarianNo, but I try to avoid red meatActivityDo you exercise? If so, what are your habits, preferences and/or limitations?Lifestyle HabitsHow many days a week do you order takeout or eat out at cafés or restaurants?No answer10-205-104-62-31-2rarelyneverHow many alcoholic beverages do you have per week on average?No answer35+20-3010-205-104-62-41-22-4 drinks a monthI don't drinkDo you do any of the following?check all that apply snack too much binge overeat none of the above If you would like, please explain more about your lifestyle habits, preferences and/or limitations.StressHow high are your stress levels?No AnswerExtreme, almost intolerableVery, I have a lot going on right nowModerate, probably the same as most peopleLow, I manage it well when it comes upHow many hours of sleep do you get a night?No answer10+9-107-85-62-41-2Additional CommentsHow did you hear about me?*check all that apply Google search Yelp Flyer Psychology Today's practitioner referral website Bing search Yahoo search Yellow pages online A friend referred me My doctor referred me Is there anything else you would like to tell me? Share Facebook Facebook Share Twitter Tweet Google+ Pinterest Email a Friend Email a Friend
