Health History Formyou might have to call in a parent for this one! Name * First Name Last Name Email * Phone # (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Age Would you like your weight to be different? If so, by how much? * Relationship Status Children? Pets? Occupation Hours of work per week What are your main health concerns? What are your current health goals? At what point in your life did you feel the best? Any serious illnesses/hospitalizations/injuries? How is/was the health of your Mother? How is/was the health of your Father? Were you born Vaginally or through Cesarean? Vaginal Birth Cesarean Were you Breastfed? Yes No How is your sleep? How many hours? Do you wake up at night? Why? Any pain, stiffness, or swelling? Constipation? Diarrhea? Gas? Allergies or sensitivities? Please explain: Men skip this question. Are your periods regular? How many day is your flow? How frequent? Painful or symptomatic? Men skip this question. What is your birth control history? Men skip this question. Do you experience yeast infections or urinary tract infections? 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? What did your diet look like as a child? Breakfast? Lunch? Dinner? Snacks? Liquids? What does your diet look like now? Breakfast? Lunch? Dinner? Snacks? Liquids? Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Yes No Not sure Do you cook? Yes No 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 for my health is: Anything else you would like to share? Yay you for taking a step towards a healthier life!I will be in touch shortly!
