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Health History Form
To help me get to know you better, please complete as many questions as you are comfortable answering. All of your information will remain confidential. Thanks! If you prefer to work from a PDF, download it
here.
Personal Information
Name
*
First
Last
Email
*
How did you hear about me?
*
How often do you check email?
Phone
Date of Birth
Month
Day
Year
Place of birth
City/state (or country) where you currently live
Height
Weight
Weight six months ago
Weight one year ago
Would you like your weight to be different?
If so, how?
At what point in your life did you feel best?
Social Information
Relationship status
Children
Grandchildren
Pets
Occupation
Hours of work per week
How long in current job?
Do you enjoy it? Briefly explain:
Do you consider yourself an extrovert or introvert?
Extrovert
Introvert
Neither
Health Goals & Information
Please list your main health concerns
Other concerns and/or wellness goals?
The most important thing I should do to improve my health is:
Rate your stress level (0 low – 10 high)
What causes your stress?
What exercise/sports do you participate in?
How many days per week do you exercise?
How long per session?
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?
Any digestive issues (constipation/diarrhea/gas/etc.)?
Allergies or sensitivities? Please explain:
Any serious illnesses/hospitalizations/injuries?
Please list any supplements or medications you take:
Please list any healers, helpers, or therapies you are working with:
Women's Health
Are your periods regular?
Yes
No
How many days is your flow?
How many days in one complete cycle?
Painful or symptomatic? Please explain:
Reached or approaching menopause? Please explain:
Birth control history:
Do you experience yeast infections or urinary tract infections or have you in the past? Please explain:
Food Information
Please describe how you ate as a child?
What foods do you eat these days for breakfast?
For lunch?
For dinner?
For snacks?
What types of liquids do you drink during the day?
Will family/friends be supportive of your desire to make food and lifestyle changes?
Do you cook?
What percentage of your food is home-cooked?
Where does the rest of your food come from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
Do you consume caffeine?
What types?
How often?
Total quantity per day?
Do you drink alcohol?
What types of alcohol?
How often (days/week or month)?
How many drinks at a time?
Additional Comments
Anything else you would like to share?
I understand that canceling or rescheduling any appointment requires AT LEAST 24-hours notice (business day) or I will be charged the full session rate.
*
Yes, I understand
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