Health History Form

Basic Information

1. Full Name(*)
2. Date
3. Email(*)
4. How often do you check email?

Location

1. Street Address(*)
2. City(*)
3. State(*)
4. Zip(*)

Contact Numbers

1. Work Phone
2. Cell Phone
3. Home Phone

Age, Birth Info, Height

1. Age
2. Date of Birth
3. Place of Birth
4. Height

Weight Info

1. Current weight
2. Weight six months ago?
3. One year ago?
4. Would you like your weight to be different? Select Answer Here Yes No
5. If so, what?

Relationship, Children, Occupation

1. Relationship status Select Status Single Married Widowed Divorced
2. Number of Childrens?
3. Occupation
4. How many hours a week do you work?

Sleep, Waking Up, Blood Type

1. Do you sleep well? Select Answer Yes No
2. Do you wake up at nights? Select Answer Yes No Sometimes Often
3. What time(s)?
4. To urinate?
5. What time do you generally get up in the morning?
6. Do you experience constipation/diarrhea? Select Answer Yes No
7. If yes, please explain
8. What blood type are you?
9. What is your ancestry?

(For Women Only)

1. Are your periods regular? Select Answer Yes No
2. How many days is your flow?
3. How frequent?
4. Painful or symptomatic? Select Answer Yes No
5. Please explain

Supplements, Therapies, Exercise

1. Do you take any supplements or medications? If so, which?
2. Are there any healers, helpers or therapies with which you are involved? Please list
3. What role does exercise play in your life?
4. Do you drink coffee, smoke cigarettes, or have any major addictions?

Foods, Illness

1. What percentage of your food is home cooked?
2. Where do you get the rest from?
3. Serious illness/ hospitalizations/ injury

Parent's Health, Concerns

1. How is the health of your mother?
2. How is the health of your father?
3. What is your chief concern?
4. Other concerns?

Foods you eat often as a child?

1. breakfast
2. lunch
3. dinner
4. snacks
5. liquids

What about one year ago?

1. breakfast
2. lunch
3. dinner
4. snacks
5. liquids

What's your food like these days?

1. breakfast
2. lunch
3. dinner
4. snacks
5. liquids

Spam Prevention

1. Enter Code

 

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