2025 Consultation Form

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What is your name?
First Name
Last Name
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What is your birth date?
Date
Year
Month
Day
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What time were you born?
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Hour
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Minutes
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What country were you born in?
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
5
If born in the USA, what stateSkip if you were not born in the USA
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Please write out what city you were born in. If you were not born in the USA, please write out the location.
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Are you male or female?
Male
Female
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If female: please provide the dates of your menstruation cycle (beginning with the day you bleed), if you are on birth control, and if so, what type/brand. If you are pre or post menopausal, please note.
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If Male: have you ever had your testosterone levels checked? If so, what are they? Are you on any type of HRT or interested in HRT?
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Are you single, married, and do you have any children? Please provide names and ages.
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Who do you live with and/or surround yourself with? Are they supportive of your journey? How so?
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What environments, perceived pressure, or social settings (who, what, where, when) influence your decisions regarding your body and health?For better or for worse!
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What are your interests, hobbies, or daily enjoyments? In other words, what do you do for fulfillment?You may also discuss your job or career here as well.
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Do you spend time understanding your thoughts and emotions? If so, how do you connect to yourself?
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What are you most interested in learning regarding your body, nutrition, and health? Please elaborate.
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What are your top 3-5 priorities in life? In other words, what is most important to your heart or sense of purpose? How is this reflected in your day to day lifestyle?
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Why are you reaching out to Body Alchemy for help? Please be specific.
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Pertaining to the last question, what previous guidance, if any, have you had in the past? Example: diet methods you have tried, books, therapy
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What did you take away from these experiences? How were they helpful? If you have never sought direction until now, please explain why.
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What does the word "health" mean to you?
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In your own words, what is quality nutrition in today's modern era? What do you consider as poor nutrition?
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What weekly and daily behaviors do you practice that promote your health? Example: Exercise or physical activity, meditation, journaling, etc
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What weekly and daily behaviors do you partake in that jeopardize your health?Example: Lack of sleep, stress eating, eating fast food, etc
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What are some poor habits or unhealthy foods/drinks that you can eliminate right now? What will you change after you submit this form?
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What are some good habits and healthy food/beverage choices that you can start right now?What will you incorporate after you submit this form?
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What is your current weight?
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What is your height?
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Please provide pictures of your front, side, and back -or text/email.Wear clothing that best represents your current body composition. IE, sports bra, athletic shorts, swim suit. QUALITY LIGHTING PLEASE.
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If you have a DEXA, InBody, or body compositions results, please upload here
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Max. file size: 10.6MB
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Please upload any lab-work from within the last year.
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Max. file size: 10.6MB
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Please list all medications you are currently on, or have used in the past for durations longer than 30 days (this includes antibiotics). Why are you or were you taking these? Please also list all current supplements; what is it, the amount taken, and the brand or supplier.Example: Vitamin D3, 10,000 IUs daily, Thorne.
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Please list ANY family history (both immediate and extended) of health problems, weight issues, and the family member’s relation to you:
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Have you ever had any surgeries? Please list what, why, and the date.
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What are your first few memories of food? Was it a positive or negative experience?
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At what age did you become conscious or aware of your body image? How did you feel toward yourself?Please explain if this was a negative or positive experience. For example; people typically describe themselves as the "skinny kid" or "fat kid"
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What were you parent's or guardian's attitude towards food, health, and/or their body images?
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Fundamental Years of Growth and Development: Under the select age categories, please identify any physical or emotional challenges you had that you are aware of. This includes physical injuries/health-related issues. Please provide details around the event such as people involved, age, place, and how you felt at the time. Examples; Broken arm,, parent's divorced, moved, alcoholic family member, abuse, chronic ear infections, death of a loved one, etc.
Age 1-7
Age 8-14
Age 15-21
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Physical Growth and Development: When did you first become physically active? Please provide a detailed explanation of physical activity you engaged in during your lifetime, starting with adolescence. This does not have to be a formal sport.Example: Played club soccer starting at 5 years old for 10 years. Joined a gym at age 20 and consistently worked out for 3 months.
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If this was not answered in the previous question, have you ever received any type of formal strength or resistance training from a coach or personal trainer? If so, what was the duration and what specifically did you work on?
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Adult Weight History and Corresponding Events: Use each age range to note your weights at that time of your life. Provide details about your body composition, if there was weight gain/loss, and if any weight or time of life was your "ideal" weight (or where you felt your best so far).
Age 20-30
Age 30-40
Age 40-50
Age 50-60
60+
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Do you have any current injuries, illness (such as autoimmune), inflammation/pain, or other physical ailments?Example: low back pain
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Do you experience indigestion, constipation, bloating, and/or diarrhea? If so, how often?
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Which type most accurately depicts your typical bowel movement?Provide your answer in the next box.
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Answer Here
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How often do you eat at or from a restaurant? Please be specific in the number of meals per day and per week.This includes lunch rooms, catered events, etc
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How many alcoholic beverages do you consume on average in a week? What type of alcohol?Example: wine, beer, bourbon, margarita
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How many hours of sleep do you average each night?.Please note what time you fall asleep at night and what time you wake up the next day.
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On a scale of 0-10, 0 being "well rested" & 10 being "didn't sleep a wink", how would you rate the quality of your sleep?Please explain your answer.
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How many hours a day do you work? How many hours a week?Please also note if you travel, work from home, or go to an office.
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How many hours a day are you sitting? What's the longest you remain seated before getting up?
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How many hours of screen time do you average?
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How often in a day or week do you get outside? For how long?
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How much caffeine do you average in a day?
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On a scale of 0-10, 0 being "lethargic and falling asleep" and 10 being "I'M ALIVE!", how would you rate your energy levels through the day?Obviously, energy levels rise and fall naturally through out the day so feel free to note when your energy is highest vs lowest.
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On a scale of 0-10, 0 being "totally relaxed" and 10 being, "totally anxious", how would you rate your daily stress levels?
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What is a calorie?
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What is a carbohydrate?
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What is a fat?
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What is a protein?
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What are micronutrients?
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What is hydration?
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What is metabolism?
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What is body fat?
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What is the immune system? How does it work?
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What is blood sugar?
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What is blood cholesterol?
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What is homeostasis?
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Terms & Conditions* This field is required.
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Do you understand that you are 100% free to make any choice regarding what you eat or drink at all times? This includes the decision to not eat or drink.
YESNO
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Do you understand that any lack of transparency regarding your diet (what you eat and drink) and physical activity will only be a hinderance to your progress and outcome?Honesty is not the policy because it is the ONLY policy
YESNO
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Do you understand that no one is responsible for your feelings, attitude, and behaviors other than you?AKA you do not make someone "feel bad" and vice versa
YESNO
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Do you understand that in order for your body to yield the results you desire, you will have to let go of the situations, attitudes, foods/beverages, and other lifestyle habits that disrupt your health and/or interfere with your goals?These may be temporary or indefinite.
YESNO
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Will you reach out and ask Body Alchemy for help or guidance when you need it?.
YESNO
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Do you understand that all physiological adaptations require acceptance, patience, and consistency?
YESNO
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Are you willing to give your body the time and space (boundaries) it needs to heal, change, and reset its homeostasis?
YESNO
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Will you communicate with your friends, family, co-workers about your dietary needs (or health goals) in an appropriate but direct fashion?
YESNO
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Are you READY to make this commitment to your self and to your body?
YESNO
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Please sign your name
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Please provide future dates of events such as travel, work functions, social engagements, that you have committed to within the next 3 months.
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Please select Meet & Greet to schedule our first official appointment over ZOOM or in-person.
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