Health History Questionnaire

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First Name:
Last Name:
Sex:
Email:
Address:
Zip/Postal Code:
City:
State/Province:
Phone Number:
Relationship status:
Family Members (Name, Type, Age):
Pets:
Occupation:
Hours per week you work:
Place of birth:
Height (n' n"):
Current weight (pounds):
Weight 6 months ago (pounds):
Weight 12 months ago (pounds):
Would you like your weight to be different:
Target Weight (pounds):
Main health concerns:
Other concerns and/or goals:
At what point in your life did you feel your best:
List any serious illnesses/hospitalizations/injuries:
How is your Paternal Mother's health:
How is your Paternal Father's health:
What is your ancestry:
What is your blood type:
Do you sleep well:
Hours of sleep per night (average):
Describe any reasons you wake up at night:
Any pain, stiffness or swelling:
Constipation/Diarrhea/Gas:
Describe any allergies or sensitivities:
Female Only
Are your periods regular:
How many days is your flow (average):
Cycle between periods (every n days on average):
Describe any painful or symptomatic problems with your period:
Birth control history:
Vaginal infections, reproductive concerns:
Reaching or approaching Menopause:
Please explain:
Describe any supplements or medications:
Describe any healers, helpers, pets or therapies with which you are involved:
What role do sports and exercise play in your life:
What foods did you eat often as a child

Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
What foods do you eat often now

Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes:
Do you cook:
What percentage of your food is home cooked (on average):
What percentage of your food is NOT cooked (on average):
Describe where you get non-home cooked food from:
Describe any cravings for sugar, coffee, cigarettes and/or major addictions:
Describe the most important thing you feel you should change about your diet to improve your health:
Describe anything else you would like to share: