Email Address:

Contact Number:

Birthdate:

Current Location:

Age:

Height:

Current Weight:

Desired Weight:

Is your physical health/weight one of your goals?

What is your Relationship Status?

Is this an area you would like to grow in?

If any Children, give names/ages:

If children, what is your perception of the relationship(s):

# of Siblings:

Briefly describe the relationship(s) with your sibling(s):

Are your parents livng?:

Briefly, describe your relationships with your parents:

Do you have any Pets?

How many people do you consider as "Close Friends"?

Occupation?

Attitude toward current career?

Please list your main health concerns"

List any past illness/hospitalizations/injuries

How many hours a night do you sleep?

How much (non work related) physical activity do you get weekly? Describe?

Describe a typical days diet:

Describe briefly your spiritual life:

Describe briefly why you want help?