HEALTH HISTORY FORM |
PERSONAL AND CONTACT INFO |
Date: |
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Full Name: |
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Address: |
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City: |
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State: |
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Zip: |
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Email: |
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How often do you check your email? |
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Phone |
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work |
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home |
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cell |
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HEALTH HISTORY |
Age |
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Height |
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Date of Birth |
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Place of Birth |
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Current weight |
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Weight 6 months ago |
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Weight one year ago |
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Would you like your weight to be
different and if so, what... |
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HOME LIFE |
Relationship status |
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Do you have children? |
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WORK LIFE |
Occupation? |
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How many hours do you work weekly? |
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SLEEP PATTERNS |
Do you sleep well? |
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Do you wake up at night? If so, when? |
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To urinate? |
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What time do you get up in the morning? |
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BODY TYPE
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Do you experience constipation/diarhhea? |
yes
no, please explain
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Blood type ? |
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What is your ancestry? |
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WOMEN ONLY |
Are your periods regular? |
yes
no, please explain
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How many days is your flow? How frequent? |
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Painful or symptomatic? |
yes, please explain
no
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PERSONAL HEALTH |
Do you take any vitamins/medications? |
yes, please explain
no
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Please list any other healers, helpers, pets, or therapies with which you are involved? |
yes, please explain
no
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What role does exercise play in your life? |
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Do you have any major addictions, drink coffee, or smoke cigarettes |
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How is your dental health? Do you have fillings? What kind? |
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Have you had any serious illness / hospitalizations/injury |
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FAMILY HEALTH HISTORY
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How is the health of your father? |
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How is the health of your mother? |
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Do you have siblings? How Many? How is their health? |
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YOUR TURN |
What are your main health concerns? |
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Other concerns |
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YOU AND FOOD
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What percentage of your food is home cooked ? Where do you get the rest from? |
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WHAT FOODS DID YOU EAT OFTEN AS A CHILD? |
Breakfast |
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Lunch |
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Dinner |
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Snacks |
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Liquids |
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WHAT FOODS DID YOU EAT ONE YEAR AGO |
Breakfast |
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Lunch |
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Dinner |
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Snacks |
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Liquids |
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WHAT IS YOUR FOOD INTAKE RIGHT NOW? |
Breakfast |
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Lunch |
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Dinner |
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Snacks |
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Liquids |
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