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Health History Form
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Gender
Male
Female
Age:
Height:
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:
Pets:
Occupation:
Hours of work per week:
Please list you main health concerns:
Other 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 father?
His is/was the health of your mother?
What is your ancestry?
What blood type are you?
Do you sleep well?
How many hours?
Do you wake up at night? If so, why?
Any pain, stiffness or swelling?
Constipation/Diarrhea/Gas? Please explain:
Do you take any supplements or medications? Please list:
Any healers, helpers or therapists with which you are involved? Please list:
What role does sports/exercise play in your life?
What foods did you eat often as a child?
What's your food like these days?
Will family/friends be supportive of your food and/or lifestyle changes/goals?
What percentage of your food is home cooked?
Do you cook?
Where do you get the rest from?
Do you crave sugar, alcohol, cigarettes, or have any major addictions?
The most important thing I should change about my diet to improve my health is:
Anything else you want to share?