Health History Form

Please fill out the form below and expect an email from me soon.

All of your information will remain confidential and its only between me and you!

Please complete the form below

Name

First Name

Last Name

Email Address

Contact phone

Age:

Height:

Birthdate :

Place of Birth:

Current Weight:

Weight 6 months ago:

One year ago :

Would you like your weight to be different?:If so, What? :

Relationship status:

Where do you currently live?

Children or Pets:

Occupation:

Hours per week?

Please list your main health concerns :

Any other concerns or goals? :

At what point in your life did you feel best? :

Any serious illnesses/ hospitalizations/ injuries?

How is the health of your mother?

How is the health of your father?

What is your ancestry?

What blood type are you?

How is your sleep?

Do you wake up at night? if so, why? :

any pain, stiffness or swelling? :

Constipation/ diarrhea/ gas?

Do you have any allergies or sensitivities ?

Females : Are your periods regular?

Females : How many days is your flow? And how Frequent?

Females : Are your cycles painful or symptomatic?

Females : Are you reaching or approaching menopause?

What is your birth control history?

Do you experience yeast infections or urniary tract infections?

Medical information

Do you take any supplements or medications? Please list

Any healers, helpers or therapies with which you are involved?

What role do sports and exercise play in your life?

Food Yum!

As a child what kind of foods would eat for Breakfast?

Lunch :

Dinner

Snacks :

Liquids :

Will famly and/or friends be supportive of your desire to make food and lifestyle changes?

Do you cook?

What percentage of your food is home-cooked?

Where do you get the rest from?

Do you crave sugar, coffee, nicotine, or have any major addictions?

The most important thing i should do to improve my health is :

What are your food choices like these days?

Breakfast :

Lunch:

Dinner:

Snacks:

Liquids:

Any other tid bits?

Anything else you would like to share?