Confidential Health History

PLEASE COMPLETE THIS FORM AFTER YOU HAVE MADE AN APPOINTMENT WITH ONE OF OUR COUNSELORS.
Name:(required)
Address:
Email address:(valid email required)

Phone Numbers

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?
If so, what?
Relationship status:
Children?
Occupation:
Hours of work 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?
Please explain:
What blood type are you?
What is your ancestry?
Women: Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic?
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?
Any serious illnesses/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?

What's your food like these days?

Attentive Health