Short Health History Form

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Becoming educated about your own body and learning about improvements in nutrition and lifestyle are steps to take more control of your health. Once the form is completed, schedule your 90-Minute session via my online calendar.
Connect how your past experiences, travels and environment
and learning about improvements in nutrition and lifestyle are steps to take more control of your health. Once the form is completed, schedule your 90-Minute session via my online calendar.
to take more control of your health. Once the form is completed, schedule your 90-Minute session via my online calendar.
Have a personal roadmap to a healthier you.

Once the form is completed, schedule your 90-Minute session via my online calendar.

Brief Health History Form

Personal Information
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Email:*
How often do you check email?:*
Phone (cell):
Statistics
Age:*
Birth Date:
MM slash DD slash YYYY
Male/Female:
Height:
Blood Type:
Current Weight:
Would you like your weight to be different?
If so, what?
Social Information
Occupation:
Family/Living Situation:
Children. If so, how many?
Are you on Social Media?
Health Information
Please list your main health concerns:
Do you have any other concerns and/or goals?
Any serious illnesses, hospitalizations or injuries?
On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy:
How is the health of your mother?
How is the health of your father?
How many hours of sleep do you get a night?
Do you wake up at night? If so, explain:
Any pain, stiffness or swelling?
Constipation, diarrhea or gas?
Allergies or sensitivities? If so, please explain:
How have you dealt with these concerns in the past?
- doctors
- self-care
Women Only
Are/were your periods regular? If not, please explain:
How many days is your flow?
How frequent?
Painful or symptomatic? Please explain:
Do you experience yeast infections or urinary tract infections? Please explain:
Medical Information
List all vitamins, minerals, herbs and nutritional supplements you are now taking:
List any medicine you are currently taking:
Any healers, helpers or therapies with which you are involved? Please explain:
How often have you taken antibiotics as an adult?
Do you have symptoms immediately after eating like bloating, gas, sneezing or hives? If so, please explain:
Food Information
Are there foods that you crave? If so, please explain:
Which of the following foods do you consume regularly?
- alchohol
- coffee
- dairy (cheese, milk, yogurt)
- diet soda
- fast food
- gluten (wheat, rye, barley)
- refined sugar
- soda
Are you currently on a special diet?
- autoimmune paleo (AIP)
- SCD/GAPS
- dairy restricted or dairy-free
- vegetarian
- vegan
- paleo
- blood type
- raw
- refined sugar-free
- gluten-free
What percentage of your meals are home-cooked?
- 10
- 20
- 30
- 40
- 50
- 60
- 70
- 80
- 90
- 100
Where do you get the rest from?
Foods you eat for breakfast:
Foods you eat for lunch:
Foods you eat for dinner:
Are you willing to move outside of your comfort zone, try new foods and make adjustments in your routines in order to achieve your health goals?
Intestinal Status
Bowel Movement Frequency:
- 1–3 times per day
- more than 3 times per day
- not regularly every day
Have you been exposed to any chemicals or toxic metals (lead, mercury, arsenic, aluminum)?
Do you have mercury amalgam fillings?
Lifestyle History
What role do sports and exercise play in your life?
What kind of relaxation techniques do you use? Are breathing, mediation, journaling, yoga etc. involved?
Other
Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain, if no.
Who in you family or on your health care team will be most supportive of you making dietary change?
What are three goals you have towards health?
Anything else you would like to share?

The information on this website in not meant to replace or dismiss medical advice from your family practitioner or any medical team.

Short Health History Form

Brief Health History Form

Personal Information

Statistics

Social Information

Health Information

Women Only

Medical Information

Food Information

Intestinal Status

Lifestyle History

Other