Health History Health History Form Health History Form This 50-minute confidential session, available by Video-Chat Personal InformationName First Last Email How often do you check email? PhoneAge Date of Birth DD slash MM slash YYYY Place of Birth Height Current Weight Weight Six Months Ago Weight One Year Ago Would you like your weight to be different? Yes No If so, what? Social InformationRelationship Status Where do you currently live? What is your living arrangements? Do you have children? If so what are their names and ages?Do you have pets? If so what are their names and type?Occupation Hour of work per week Health InformationPlease list your main health concernsOther concerns and/or goals?At what point in your life did you feel your best?Any serious illnesses/hospitalizations/injuries?How is/was the health of your mother?How is/was the health of your father?What was your birth like?What is your ancestry? What blood type are you? How is your sleep? How many hours do you sleep? Do you wake up at night? Why?Any pain, stiffness, or swelling?Constipation/Diarrhea/Gas?Allergies or sensitivities? Please explain:Medical InformationDo you take any supplements or medications? Please list:Any healers, helpers, or therapies with which you are involved? Please list:What role does sports and exercise play in your life?Food Information - What foods did you eat as CHILD?BreakfastLunchDinnerSnacksLiquidsFood Information - What is your food like these days?BreakfastLunchDinnerSnacksLiquidsWill family and/or friends be supportive of your desire to make food and/or lifestyle changes?Do you cook? What percentage of your food is home-cooked?Where do you get the rest from?Do you crave sugar, coffee, cigarettes, or have any major addictions?The most important thing I should change about my diet to improve my health is:Additional CommentsAnything else you would like to share?
