Home
About
Naomi Lewis
Autoimmune Protocol
Whole 30
Paleo
Services
Consulting
Autoimmune Protocol
Whole30 Reset
Paleo Diet
Work with me
Home
About
Naomi Lewis
Autoimmune Protocol
Whole 30
Paleo
Services
Consulting
Autoimmune Protocol
Whole30 Reset
Paleo Diet
Work with me
Name
*
First Name
Last Name
Date
*
Address (City, State, Zip)
*
Phone
Email Address
*
Date of Birth
*
What is your major complaint or goal you would like to address?
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What do you hope to accomplish or change in our work together?
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What do you consider a realistic window of time to see changes?
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Do you feel satisfied with your current diet?
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On a scale from 1-10 (10 being the highest) how committed are you to changing your health?
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What obstacles stand in your way?
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What is your opinion on what has happened to your health?
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What percentage of your meals are cooked fresh from home?
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What are a few examples for each meal? (Breakfast, Lunch, Dinner, Snacks)
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List at least one example per meal
On average how many times a week are you eating meals out?
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Do you consume any artificial sweeteners?
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Do you have cravings for certain foods or flavors? How often?
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How is your energy level?
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How do you cope with stress?
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How often do you exercise, and what type?
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Do you consume any alcohol?
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How is your sleep? Do you feel refreshed in the morning?
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Do you have any environmental food or allergies?
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Are you currently seeing any other health practitioners?
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Have you had any serious illness, injuries, or operations? If so, when?
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Are you currently taking any prescription drugs? If so, which and when?
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Are you taking any vitamin supplements? Please list.
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Is there any other information I haven't asked you that you want to tell me?
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Thank you!
I LOOK FORWARD TO WORKING WITH YOU!
