Health History

Thank you for trusting me to work with you! This form is a comprehensive Health History, so I can catalog as much as possible about your past and current health, allowing our plan to be more effective together.

First name

Last name

Country

Address

Add Line 2

Address line 2 (optional)

Zip code

City

State

Mobile phone

Age

Gender

Male

Female

Current Weight

Weight 6 Months Ago

Would you like your weight to be different? Why?

SOCIAL INFORMATION

Relationship status:

Where do you currently live?

Children?

HEALTH INFORMATION

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?

Text

How is your sleep? Hours? Do you wake up at night?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain:

WOMEN’S HEALTH

Are your periods regular? How many days is your flow? How Often?

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?

What is your food like these days?

Will family and/or friends be supportive of your desire to make food and/or 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, 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?