Health History Form

Please be honest and clear.

* Indicates required field

Name *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Age *

Height *

Current Weight *

6 Months Ago *

How often do you check email? *

Birth Date *

Place Of Birth *

1 Year Ago *

Do You Want A Different Weight? *

If so, what? *

Relationship Status *

Children? *

Pets? *

Occupation *

Hours Of Work Per Week *

Main Health Concerns *

Other Concerns/Goals? *

When In Life Did You Feel Best? *

Any Serious Illness? *

Mother's Health? *

Father's Health? *

What Is Your Ancestry? *

What Is Your Blood Type? *

Sleep Well? *

How Many Hours? *

Do You Wake Up At Night & Why? *

Any Pain, Stiffness, Swelling? *

Birth Control History *

Yeast Or Urinaruy Tract Infections *

Constipation/Gas/Diarrhea? *

Allergies Or Sensitivities? *

Any Supplements/Medications? *

Do You See Any Healers/Therapists? *

Does Exercise Play a Role In Your Life? *

What Foods Did You Eat as a Child? *

What's Your Food Like These Days? *

Will Family/Friends Support Your Desire To Change? *

% of Food That's Home Cooked? *

Do You Cook? *

Where Do You Get The Rest From? *

Cravings? Sugar/Cigarettes/Coffee? *

Any Major Addictions? *

List three things that you know you should change to be healthier. *

Anything Else You Want To Share? *

Females Only

Are Your Periods Regular? *

How Many Days Is Your Flow? *

How Frequent? *

Menopause? Please Explain? *

Painful Or Symptomatic? Explain? *

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