Your Health History Form Your Health History Step 1 of 7 14% Personal Information Name FirstLast Email How often do you check email? Phone [Home] Phone [Work] Phone [Mobile] Age —161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100 Height Birthdate Month123456789101112 Day12345678910111213141516171819202122232425262728293031 Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Place of Birth Current Weight Weight Six Months Ago Weight One Year Ago Would you like your weight to be different? Yes No If so, what? Social Information Relationship Status Where do you currently live? Children Pets Occupation Hours of Work Per Week Health Information 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 (if you know)? How is your sleep? How many hours of sleep do you typically get? Do you wake up at night? If so, why? Pain, stiffness or swelling? Constipation / Diarrhea / Gas? Allergies or sensitivites? Please explain Women's Health Are your periods regular? Yes No 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 excercise play in your life? Food Information What foods did you eat often as a child for BREAKFAST? What foods did you eat often as a child for LUNCH? What foods did you eat often as a child for DINNER? What foods did you eat often as a child for SNACKS? What foods did you eat often as a child for LIQUIDS? What is your food like these days for BREAKFAST? What is your food like these days for LUNCH? What is your food like these days for DINNER? What is your food like these days for SNACKS? What is your food like these days for LIQUIDS? Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Yes No Not Sure Do you cook? Yes No 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 Comments Anything else you would like to share?