Initial Consultation Form

* Today's Date:

* First & Last Name

* Street Address

* City

* State

* Zip Code

* Phone Number

* Email Address

* Relationship Status

* Children &/or Pets? (Please list names & ages):

* Occupation & Average Hours Work per Week

* List Any Serious Illnesses &/or Hospitalizations with Dates

* Place of Birth

* Foods Most Commonly Eaten as a Child

* Date of Birth:

* Height:

Weight History

	Current Weight	Weight 6 Months Ago	Weight 1 Year Ago	Desired Goal Weight
Pounds (Lbs.)

Please list the foods & beverages you most commonly eat throughout the week - including weekends.

	Breakfast	Lunch	Dinner	Snacks
Food & Drinks

Please list your exercise activities.

	Types	Minutes	Times per Week
Activities

Please fill in any details on these health related issues:

	Allergies &/or Sensitivities	Medications &/or Supplements	Cravings &/or Addictions (coffee, sugar, nicotine)	Additional Healers &/or Therapists	Birth Control
Details

* Hours Sleep per Night

* Do you experience any of the following:

	Yes	No	Sometimes	N/A (Gender)
Pain, Stiffness &/or Swelling?
Constipation, Diarrhea &/or Gas?
Yeast or Urinary Tract Infections?
Regular Menstrual Periods?
Painful Menstrual Periods?
Menopause Symptoms?

* The Most Important Thing I Should Change About My Diet Is:

* Will Friends & Family Be Supportive of You Making Food &/or Lifestyle Changes (be specific):

* What Percent of Your Food is Home Cooked? Do You Cook? Do You Eat Out? Please Be Specific.

* At What Point in Your Life Did You Feel Your Best? Please Be Specific.

* List Your Main Health Concerns & Goals for the Next Year:

* Please List Anything Additional You Would Like to Share:

* Indicates Response Required

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reJoyce Health, LLC
Colleen Joyce Pontes - Weight Loss Coach, Owner, CHCC, AADP
www.reJoyceHealth.com
rejoycehealth@me.com or 718.644.6397 (call or text)
It Works! Weight Loss Products:
www.rejoyce.myitworks.com