Meet Erika Fore, CHC
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Healthy Restaurant Reviews
Juices & Teas
Sauces & Dressings
Tofu & Tempeh
Women’s Health History
Telephone - Home
Telephone - Cell
Preferred method of contact
Phone Call - Cell
Phone Call - Email
Date of birth
Place of birth
Weight six months ago
Weight one year ago
Would you like your weight to be different?
If so, what?
Hours per week
Please list your main health concerns
Other concerns and/or goals?
At what point in your life did you feel best?
Any serious illnesses/hospitalizations/injuries?
How is/was the health of your mother?
How is/was the health of your father?
What is your ancestry?
What blood type are you?
Do you sleep well?
How many hours?
Do you wake up at night?
If so, why?
Any pain, stiffness or swelling?
Are your periods regular?
How many days is your flow?
Painful or symptomatic? Please explain
Reached or approaching menopause? Please explain
Birth control history
Do you experience yeast infections or urinary tract infections? Please explain
Constipation/Diarrhea/Gas? Please explain
Allergies or sensitivities? Please explain
Do you take any supplements or medications? Please list
What role does sports and exercise play in your life?
What foods did you eat often as a child?
What’s your food like these days?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
What percentage of your food is home cooked?
Do you cook?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should change about my diet to improve my health is
Anything else you want to share?
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