New Client Questionnaire Name(required) Email(required) Date of Birth: mm/dd/yyyy(required) Street Address(required) City(required) Zip(required) Employer/Occupation(required) Name of Spouse(required) Last Physician Consulted(required) Reason for that visit Who may we thank for referring you? (check all that apply) Friend (write name in comment box below) Event (write name in comment box bellow) Professional Referral (write name in comment box bellow) Internet Flier/Brochure Ad Name of the person who referred you What are your top 3 health concerns?(required) What are your goals for working with Paleo Spectrum (weight loss/how much, improved health/how, reduce/eliminate prescription meds, etc.)(required) Current Rx Medications Current OTC medications Current Vitamins/Herbs/Supplements Drug Allergies Other Allergies Sleep (hours per night, broken or unbroken, etc.)(required) Daily Screen Time (tv, computer, tablet, cell phone, gaming systems, etc.) Family/Play Time (daily hours spent uninterrupted with family, friends or alone): Smoking/Vaping Type of Exercise (cross training, yoga/pilates, weight training, walking, high intensity, endurance, etc): Do you participate in competitive events?(required) Yes No If so, how often? Gym/Box/Coach/Trainer Typical diet (please list foods normally eaten at these meals) Breakfast(required) Lunch Dinner Snacks (please include time of day) Childhood Illnesses Adult Illnesses Hospitalizations Surgeries Injuries Diagnoses (auto-immune disease, thyroid disorders, fatty liver, arthritis, etc.) Current and past Health Current Weight(required) Weight 1 year ago Maximum Weight Minimum Weight Are you currently experiencing any symptoms or conditions which concern you?