Health History Form

Name

First Name

Last Name

Email Address

Cell Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age

Date of Birth

YYYY

Place of Birth

Relationship Status

Children

Pets

Occupation

Health Information

Current weight

Ideal Weight

At what point in your life did you feel best?

What are your main health concerns?

Any serious illnesses/ hospitalizations / injuries?

Do you have pain, stiffness or swelling?

Do you have constipation/ diarrhea or gas?

Do you have food allergies or sensitivities?

Do you have other allergies?

Are you taking any supplements or medications?

Are you working with any doctors/ healers / therapists?

Women's Health Information

Are your periods regular?

What is your birth control history?

Have you reached / are you approaching menopause?

Do you experience yeast or urinary tract infections?

Family Health History

What is your ancestry?

How is/was the health of your mother?

How is/was the health of your father?

Lifestyle Information

How is your sleep?

How many hours? Do you wake up at night? Why?

How is your stress level?

Do you exercise?

What? How many hours a week?

What do you do for relaxation?

What do you do for fun?

Food Information

What foods did you typically eat as a child?

Breakfast/ Lunch/ Dinner/ Snacks/ Liquids

What foods do you typically eat now?

Breakfast/ Lunch/ Dinner/ Snacks/ Liquids

Do you cook?

What percentage of your food is home-cooked? Where do you get the rest from?

What is your most favorite food?

Do you crave sugar, caffeine, cigarettes or have other food addictions?

What is the main thing you want to change about your diet?

Will family/ friends be supportive of your desire to make food / lifestyle changes?

Intentions and Goals

My health goals are:

My life goals are:

Additional information I would like to share: