Health History Form

Please complete this form to the best of your ability. If you have any questions about this, please get in touch with me.

Introduction

Name

First Last

What is your preferred pronoun?

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is your preferred method of contact?

Email

Phone

Text

Email Address

Work Phone

Home Phone

Health Questionnaire

Please complete this form to the best of your ability.

Age

Height

Date of Birth

Place of Birth

What is your ethnic ancestry?

Current Weight

Weight Six Months Ago

Weight One Year Ago

Would you like your weight to be different? If so, what?

Relationship Status

Children?

Pets?

Occupation

Hours of work per week?

What is your work environment like?

Do you sleep well?

Do you wake up at night? If so, when and why?

What time do you generally get up in the morning?

Do you experience constipation/diarrhea?

If you know, what is your blood type?

Are you menstruating?

Please skip if this is not applicable to you.

Are your periods regular?

Please skip if this is not applicable to you.

How frequent is your period?

Please skip if this is not applicable to you.

How many days is your flow?

Please skip if this is not applicable to you.

Painful or symptomatic periods? Please explain:

Please skip if this is not applicable to you.

Any known allergies or sensitivities?

Do you take any vitamins or supplements? If so, which?

Do you take any over the counter mediations or prescription medications? If so which?

Any serious illness/hospitalizations/injuries?

What is your chief medical concern?

Other concerns?

Are there any healers, helpers, or therapies with which you are involved? Please list:

What role does sports/exercise play in your life?

Do you drink coffee, smoke cigarettes, or have any major addictions?

How is the health of your mother?

How is the health of your father?

What products do you use to clean your home and laundry?

What products do you use for skincare, personal care, or beauty?

What types of personal care products do you use on your children and/or pets?

Do you burn candles, incense, or use air fresheners? If so, please explain.

Do you have plants in your home? Please explain.

Food and Cooking

Below are food-related questions. Please answer to the best of your ability.

What percentage of your food is home cooked? If your food is not home-cooked, where does it come from?

Do you skip meals? If so, why?

What type of cookware do you use?

What do you use to store your food?

What foods did you eat often as a child?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

What foods did you eat often one year ago?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

What food do you like these days? Do you skip meals?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

How much water do you drink each day?

Where do you get your water from? Bottled water, filtered water, tap water?

Is there anything else that you feel is important for me to know?