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HEALTH HISTORY FORM

PERSONAL AND CONTACT INFO

Date:
Full Name:
Address:
City:
State:
Zip:
Email:
How often do you check your email?
Phone
work
home
cell

HEALTH HISTORY
Age
Height
Date of Birth
Place of Birth
Current weight
Weight 6 months ago
Weight one year ago
Would you like your weight to be
different and if so, what...

HOME LIFE

Relationship status
Do you have children?

WORK LIFE

Occupation?
How many hours do you work weekly?

SLEEP PATTERNS

Do you sleep well?
Do you wake up at night? If so, when?
To urinate?
What time do you get up in the morning?

BODY TYPE

Do you experience constipation/diarhhea?

yes       no, please explain


Blood type ?
What is your ancestry?

WOMEN ONLY
Are your periods regular?
yes      no, please explain
How many days is your flow? How frequent?
Painful or symptomatic?

yes, please explain      no

PERSONAL HEALTH

Do you take any vitamins/medications?

yes, please explain      no
Please list any other healers, helpers, pets, or therapies with which you are involved?

yes, please explain      no
What role does exercise play in your life?
Do you have any major addictions, drink coffee, or smoke cigarettes
How is your dental health? Do you have fillings? What kind?
Have you had any serious illness / hospitalizations/injury

FAMILY HEALTH HISTORY

How is the health of your father?
How is the health of your mother?
Do you have siblings? How Many? How is their health?

YOUR TURN

What are your main health concerns?
Other concerns

YOU AND FOOD

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

WHAT FOODS DID YOU EAT OFTEN AS A CHILD?

Breakfast
Lunch
Dinner
Snacks
Liquids

WHAT FOODS DID YOU EAT ONE YEAR AGO

Breakfast
Lunch
Dinner
Snacks
Liquids

WHAT IS YOUR FOOD INTAKE RIGHT NOW?
Breakfast
Lunch
Dinner
Snacks
Liquids