CONFIDENTIAL HEALTH HISTORY FORM

Name

First Name

Last Name

Email address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best phone number

(###)

###

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Referred by

Age/DOB

Height/Weight

Would you like weight to be different?

Relationship status

Occupation

Include number of hours per week

Children?

Include ages

Main health concerns

Other concerns

Serious Injuries/Hospitalizations

How is the health of your mother?

How is the health of your father?

What is your ancestry?

What is your blood type?

Do you sleep well? How many hours?

If not, please explain

Do you have pain, stiffness, swelling?

Please explain

How is digestion?

Do you experience bloating, gas, constipation or diarrhea?

Women: Is your cycle regular? Do you experience any pain or other symptoms?

Women: Birth control history

Reproductive or fertility concerns?

Do you take supplements or medications?

Please list

Please list any healers, therapies, pets or other support systems

What role do sports and exercise play in your life?

What are the 3 healthiest foods or beverages you consume in an average week?

What are the 3 UNhealthiest foods or beverages you consume in an average week

What foods did you eat often as a child?

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Beverages

Include number of glasses of water per day

What percentage of your food is home cooked?

Where do you get the rest from?

Do you crave coffee, sugar, cigarettes, or have any major addictions?

What does your current self-care routine look like?

Any additional comments?