Health History Form

Client Name:
Date:
Address:
City:
State:
Zip:
E-mail Address:
How often do you check email?
Work Phone:
Home Phone:
Cell Phone:
Age:
Height:
Date of Birth:
Place of Birth:

Current Weight?
Weight six months ago?
One year ago?
Would you like your weight to be different?	Yes: No:
If so, what?
Relationship status:
Children?
Occupation:
How many hours a week do you work?
Do you sleep well?	Yes: No:
Do you wake up at nights?	Yes: No:
If so, what time(s)?
To urinate:
What time do you generally get up in the morning?
Do you experience constipation/diarrhea	Yes: No:
If yes, please explain:
What blood type are you?
What is your ancestry?
Women:
Are your periods regular?	Yes: No:
How many days is your flow?
How frequent?
Painful or symptomatic?	Yes: No:
Please explain:
Do you take any supplements or 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 get the rest from? Serious illness / hospitalizations / injury How is the health of your mother? How is the health of your father? What is your chief concern? Other concerns? 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: