Health History Form

For Men For Women

PERSONAL INFORMATION

First Name

Last Name

E-mail

How often do you check email?

Age

Mobile Phone

Home Phone

Work Phone

Height

Date of Birth

Place of Birth

Current weight

Weight six months ago

Weight one year ago

Would you like your weight to be different? If so, what?

SOCIAL INFORMATION

Relationship status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week

HEALTH INFORMATION

What blood type are you?

How is your sleep?

How many hours?

Do you wake up at night?

Why do you wake up at night?

Please list your main health concerns

Other concerns and/or goals?

At what point in your life did you feel best?

Any pain, stiffness, or swelling?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain

Any serious illnesses/hospitalizations/injuries?

WOMEN’S HEALTH

Are your periods regular?

How many days is your flow?

How frequent?

Painful or symptomatic? Please explain

Reached or approaching menopause? Please explain

Birth control history

Do you experience yeast infections or urinary tract infections? Please explain

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?

FOOD INFORMATION

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

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

ADDITIONAL INFORMATION

Anything else you would like to share?