Health Form

Health History

All of your information will remain confidential

Personal Information

First Name *

Last Name *

Email *

How often do you check e-mail:

Home Phone:

Work Phone:

Mobile Phone:

Age :

Height :

Birthdate: Month

Day

Year

Place of Birth:

Current weight:

Weight six months ago:

One year ago:

Would you like your weight to be different?

If so, what?

Relationship status:

Where do you currently live?

Children:

Pets:

Occupation:

Hours of work per week:

Please list your main health concerns:

Other concerns and/or goals?:

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

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?:

What blood type are you?:

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:

Medical Information :

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

What role do sports and exercise play in your life?:

Food Information

Lunch:

Dinner:

Snacks:

Liquids:

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

Do you cook?:

What percentage of your food is home-cooked?:

Where do you get the rest from?:

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

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

What is your food like these days?

Lunch

Dinner:

Snacks:

Liquids:

Additional Comments

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HEALTH FORM

Health History

All of your information will remain confidential

Personal Information

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