Health History Form

Name:
Email:
Phone:
Age:
Height:
Birthdate:
Birthplace:
Current weight:
Weight six months ago:
Would you like your
weight to be different?
yesnonot sure
If so, what?
Relationship status:
Where do you
currently live?
Children and their ages:
Pets:
Occupation:
Hours of work per week:
Please list your main health
concerns and health goals:
Any serious illnesses/
hospitalizations/injuries?
How is/was the health
of your mother?
How is/was the health
of your father?
What blood type are you?
How is your sleep? Hours?
Any pain, stiffness,
or swelling?Describe
Constipation/Diarrhea/Gas?
Allergies or sensitivities?
Please explain:
Are your periods regular?
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
or urinary tract infections?
Please explain:
Do you take any supplements
or medications? Please list:
What role do sports and
exercise play in your life?
What foods did you
eat often as a child?
What is your food
like these days?
Who will be supportive
of you to make food and/or
lifestyle changes?
Do you Cook?
What percentage of your
food is home-cooked?
Do you crave sugar,
coffee, cigarettes, or have
any major addictions?
The most important
thing I should do to
improve my health is:
Anything else you'd
like to add?