Confidential Health History Form Please fill out and click submit button
Name:
Address:
Email address:
How often do you check your e-mail?:
Telephone-Home:
Work:
Cell:
Age:
Height:
Date of birth:
Place of birth:
Current weight:
Weight six months ago:
Weight one year ago:
Would you like your weight to be different?:
If so, what?:
Relationship status:
Children:
Occupation:
Hours worked per week:
Do you sleep well?:
Do you wake up at night?:
What times?:
To urinate?:
What time do you generally get up in the morning?:
Constipation/Diarrhea?:
Explain:
What blood type are you?:
What is your ancestry?:
Women only
Are your periods regular?:
How many days is your flow?:
How frequent?:
Painful or symptomatic?:
Please explain?:
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Do you take any medications? If so, which?:
Are there any healers, helpers or therapies with which you are involved? Please list:
What role does exercise play in your life?:
Do you drink coffee, smoke cigarettes, or have any major addictions?:
What percentage of your food is home cooked?:
Where do you ge the rest?:
Serious illness/hospitalizations/injuries?:
What is your chief concern?:
Other concerns?:
How is the health of your mother?:
How is the health of your father?:
What foods did you eat often as a child, breakfast?:
Lunch:
Dinner:
Snacks:
Liquids:
What about one year ago, breakfast?:
Lunch:
Dinner:
Snacks:
Liquids:
What's your food like these days, breakfast?:
Lunch:
Dinner:
Snacks:
Liquids: