Health History Form

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Order Number

PERSONAL INFORMATION

First Name *

Last Name *

Email *

Phone Number *

Age *

Height (in inches) *

Date of Birth *

Place of Birth

Current Weight *

Weight 6 Months Ago *

Weight 1 Year Ago *

Would you like it to be different? If so, how?

SOCIAL INFORMATION

Relationship Status *

Where do you live?

Any children? *

Any pets? *

Occupation? *

How many hours do you work per week? *

GENERAL HEALTH INFORMATION

What are your main health concerns? *

Any other concerns and/or goals?

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

Any current or previous serious illnesses, hospitalizations, or injuries? *

How is your mother’s health? *

How is your father’s health? *

What is your ancestry?

What is your blood type?

How is your sleep? *

How many hours do you sleep per night? *

Do you wake up during the night? If so, why? *

Any pain, stiffness, or swelling?

Any constipation, diarrhea, or gas?

Any allergies or sensitivities? *

WOMEN’S HEALTH

Are your periods regular? *

Yes

How many days? *

How frequent? *

Are your periods painful or symptomatic? If so, please explain.

Have you reached or are you approaching menopause? If so, please explain.

What is your birth control history?

Do you experience yeast infections or urinary tract infections? If so, please explain.

MEDICAL INFORMATION

List all supplements or medication

Are you involved with any healers, helpers, or therapists?

What role do sports and exercise play in your life?

FOOD INFORMATION

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

Do you cook? *

Yes

What percentage of your food is home-cooked? *

Where does your non-home-cooked food come from? *

What foods did you eat often as a child?

Breakfast *

Lunch *

Dinner *

Snacks & Liquids *

What foods do you typically eat these days?

Breakfast *

Lunch *

Dinner *

Snacks & Liquids *

Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?

What is the most important thing you should change about your diet to improve your health? *

ADDITIONAL COMMENTS

Is there anything else you would like to share?

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