Age:
Sex:
Height:
Shape: (Thin, Medium, Large, Sporty, Overweight)
Current weight (Kg): / Ideal weight (Kg):
Blood pressure:
Have you seen your doctor or other practitioners:

REASON FOR CONSULTATION
– Physical / Psychological / Diseases / Sensation:
– Goal / Desired outcome :

SITUATION
– Married / Divorced / Single
– Children: (number, sex, age)
– Professional:
– Social:
– Environment:
– Others:

HISTORY
– Diseases / Accidents (Childhood, Adult):
– Heredity (health information of your family)
– Treatments, Supplements and other care :
– Dietary supplements and other care (eg. osteopathy, acupuncture…):

Food and activity (during the last 24 hours)
– Morning:
– Noon:
– Snacks:
– Evening:
– Drinks:
– Physical activity:
– Tobacco / Alcohol / Drugs: