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Health History
PERSONAL INFORMATION
Name
*
First Name
Last Name
Email
*
How often do you check email?
*
Phone
*
(###)
###
####
Age
*
Height
*
Birthdate
*
MM
DD
YYYY
Place of birth
*
Current weight
*
Weight six months ago
*
Weight one year ago
*
Would you like your weight to be different?
*
Yes
No
If so, what?
*
HEALTH INFORMATION
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?
*
How is your sleep?
*
How many hours?
*
Do you wake up at night?
*
Yes
No
Why?
*
Any pain, stiffness, or swelling?
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Constipation/Diarrhea/Gas?
*
Allergies or sensitivities? Please explain:
*
WOMEN'S HEALTH
Are your periods regular?
*
Yes
No
How many days is your flow?
*
How frequent?
*
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
*
MEDICAL INFORMATION
Do you take any supplements or medications? Please list
*
Any healers, helpers, or therapies with which you are involved? Please list
*
What role do sports and exercise play in your life?
*
FOOD INFORMATION
What foods did you eat often as a child?
Breakfast
*
Lunch
*
Dinner
*
Snacks
*
LIquids
*
What is your food like these days?
Breakfast
*
Lunch
*
Dinner
*
Snacks
*
Liquids
*
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
*
Yes
No
Do you cook?
*
Yes
No
What percentage of your food is home-cooked?
*
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Where do you get the rest from?
*
Do you crave sugar, coffee, cigarettes, or have any major addictions?
*
The most important thing I should do to improve my health is
*
ADDITIONAL COMMENTS
Anything else you would like to share?
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