Health History Form

Client Name:    Date:

Address:    City:    State:    Zip:

Email Address:    How often do you check email?

Telephone - Work:    Home:    Cell:

Age:    Height:    Date of Birth:

Place of Birth:

Current weight: Weight six months ago? One year ago?

Would you like your weight to be different?

Yes

If so, what?

Relationship status: Children?

Occupation:

How many hours a week do you work?

Do you sleep well?

Yes

Do you wake up at nights?

Yes

What time(s)?

To urinate: What time do you generally get up in the morning?

Do you experience constipation/diarrhea?

Yes

If yes, please explain

What blood type are you? What is your ancestry?

Women:

Are your periods regular?

Yes

How many days is your flow? How frequent?

Painful or symptomatic?

Yes

Please explain

Do you take any supplements or medications? If so, which?

Are there any healers, helpers or therapies with which you are involved? Please list:

What role does exercise play in your life ?

Do you drink coffee, smoke cigarettes, or have any major addictions?

What percentage of your food is home cooked ? % Where do you get the rest from?

Serious illness / hospitalizations / injury

How is the health of your mother?

How is the health of your father?

What is your chief concern?

Other concerns?

What foods did you eat often as a child?

breakfast

lunch

dinner

snacks

liquids

What about one year ago?

breakfast

lunch

dinner

snacks

liquids

What's your food like these days?

breakfast

lunch

dinner

snacks

liquids