Health History

Health History
Please complete and submit this form prior to our scheduled call
Personal Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Place of birth
Height
Gender
Current Weight
Weight 6 months ago
Weight 1 year ago
Would you like your weight to be different? If so, what?
Social Information
Relationship Status
Where do you currently live?
Occupation
Hours of work per week
Children
Pets
Health Information
Please list your main health concerns
Tell me about your goals
At what point in you life did you feel at your best?
Any serious injuries or hospitalisations?
How was / is the health of your mother?
How was / is the health of your father?
What is your ancestry?
What blood type are you?
How is your sleep?
How many hours do you sleep on average?
Do you wake up at night? When? Why?
Any pain stiffness or swelling?
Constipation, diarrhoea, gas?
Any allergies or sensitivities?
Women's Health

Guys, you can go to the next section on Medical Information
Do you menstruate?
Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic? Please explain
Birth control history
If you have children, how were their births?
Do you experience yeast infections or urinary tract infections?
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?
What's your energy like?
Food Information
What foods did you eat often as a child? Please give two or three examples for each category
Breakfast
Lunch
Dinner
Snacks
Drinks
What's your food like these days? Please give two or three examples for each category.
Breakfast
Lunch
Dinner
Snacks
Drinks
Will family and/or friends be supportive of your desire to make changes to what you eat and / or your lifestyle?
Do you cook?
What percentage of your food is prepared at home?
Where do you get the rest of your food from?
Do you crave sugar, caffeine, cigarettes or have any major addictions?
The most important think i could do for my health is...
Additional Information
Anything else you would like to share?
Should be Empty:

Health History

Personal Information

Social Information

Health Information

Women's Health

Medical Information

Food Information

Additional Information