Health History Form

Health History

Personal Information

Name

Email Address

Phone Number

Date of Birth

Height

Current Weight

Weight six months ago

Weight one year ago

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

Social Information

City of Residence

Relationship Status

Children

Pets

Occupation

Hours of work per week

Health Information

Please list your main health concerns

Any other concerns and/or goals?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

How is your sleep?

How often and how long do you sleep?

Any pain, stiffness, or swelling?

How often do you have bowel movements?

Any constipation or diarrhea?

At what point in your life did you feel best?

Women's Health Information

How regular are your periods?

How many days in a flow?

Painful or symptomatic? Please Explain:

Reached or approaching menopause?

Birth Control History:

Do you experience yeast or urinary tract infections?

Medical Information

Do you take any supplements?

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

What role do sports and exercize play in your life?

Do you have any allergies or sensitivities?

Food Information

Typical breakfast?

Typical lunch?

Typical dinner?

Typical snacks/drinks?

Do you typically cook or eat out?

What percent of the time do you make homecooked meals?

Do you have any food cravings or addictions?

Additional Comments

Will your family be supportive?

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

Anything else you would like to share?