Health History Form

Fill out and submit a Health History Form. This form will allow me to get to know you a little better and to have a better understanding of how I may be able to help you. I'll be in touch shortly!

Your privacy is my priority. This form is secure and all information will remain confidential.

Personal Information

First Name

Birthday

Last Name

Phone

Age

Where Were You Born?

Height

Weight

Weight 6 Months Ago

Weight 1 Year Ago

Weight Goals

Maintain My Weight

Gain Weight

Lose Weight

Social Information

Relationship status:

Children?

Occupation

Where Do You Currently Live?

Pets?

Hours of Work Per Week

Health Information

Please list your main health concerns:

Other concerns and/or goals?

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

Any serious illnesses/hospitalizations/injuries?

How was/is the health of your mother?

How was/is the health of your father?

What is your ancestry?

How is your sleep?

How many hours?

What blood type are you?

Do you wake up at night?

Why?

Any pain, stiffness or swelling?

Constipation/diarrhea/gas?

Allergies or sensitivities? Please explain:

Women's Health (for the ladies only)

Are your periods regular?

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 thrapies with which you are involved?

What role do sports and exercise play in your life?

Food Information

What Foods did you eat often as a child?

Breakfast:

Snacks:

Lunch:

Liquids:

Dinner:

What is your food like these days?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Will your 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, alcohol or have any major addictions?

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

Additional Comments

Is there anything else you'd like to share?

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Thank You For Submitting Your Health History! I'll Be In Touch Soon!