Health History and Assessment Form
Personal Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
 -
Month
 -
Day
Year
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Age
*
Gender
*
Please Select
Female
Male
Non-Binary/Non Conforming
Prefer Not to Answer
Sex At Birth
*
Please Select
Female
Male
This field allows us to more accurately make a health assessment
Your Weight in Lbs at:
*
Enter your Weight and Height for BMI:
*
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Social Information
Relationship Status
*
Please Select
Single
In a Relationship
Married
Divorced
Widowed
Children
*
Occupation
*
Hours/Week
*
Health Information
Please Check any Conditions that Apply:
Rows
Myself
Father
Mother
Sibling
Grand
Parent
High Blood Pressure
Thyroid
High Cholesterol
Diabetes
Asthma
Allergies
Eczema
Mirgraines
Cancer
Please check any other Concerns that Apply:
Rows
Myself
Father
Mother
Sibling
Grand
Parent
Heart Disease
Auto-Immune
Musculoskeletal
Metabolic/Endocrine
Neurological
Gastrointestinal
Dermatologic
Mental Health
Describe Additional Health Concerns (if Any) :
Any Hospitalizations or Surgeries, Please List by Year:
List any Medications or Supplements:
If taken, include Medical Marijuana
Sleep Quality
*
Please Select
Excellent - Wake Energized
Good - Wake Refreshed
Poor - Wake Tired
Very Poor - Difficulty to Wake
Sleep Hours
*
Please Select
1
2
3
4
5
6
7
8
9+
Sleep Integrity
*
Please Select
Sleep Through Night
Wake Up 1 time at Night
Wake Up 1-2 times at Night
Wake Up 2 + at Night
Women's Health
Menstrual Cycles
Please Select
YES
NO
Peri-Menopausal
Menopause
Flow (No. Of Days)
Please Select
1
2
3
4
5
6
7 +
Frequency
Oral Contraceptives History
eg. Birth Control
Please Describe any Menstrual or Reproductive Concerns/History:
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Lifestyle Information
Smoke
*
Please Select
YES
NO
Alcohol Consumption
*
Please Select
0-1 a week
1-2 a week
2-3 a week
4-5 a week
Daily
Rarely Drink (Usually an Occasion)
Do Not Drink
Activity
*
Please Select
None
30 mins or less
30-45 mins
45-1 hours
1 hour +
PER DAY
Per Week
*
Please Select
1 Time/Week
2 Time/ Week
3 Time/Week
4 Time/Week
5 Time/Week
6 Time/Week
Everyday
List All Activities
List (if any) Weekly Self-Care and Duration (mins/hrs)
Eg. Massage, Golf, Meditation etc... any activity to take care of yourself
Water Intake - DAILY
*
Please Use Total Ounces . 1 Glass is 8 oz.
All Other Beverages in Ounces or Cups - DAILY
*
Vegetable/ Fruit Intake - DAILY
*
Please Select
1 SERVING PER DAY
1-2 SERVINGS PER DAY
2-3 SERVINGS PER DAY
3-4 SERVINGS PER DAY
4 + SERVINGS PER DAY
1 Serving = 1 cup raw veggies, 2 cups leafy green, 1 cup raw fruit or medium sized whole fruit (takes up 1 quarter of dinner plate)
Whole Grains Intake - DAILY
*
Please Select
1 SERVING PER DAY
1-2 SERVINGS PER DAY
2-3 SERVINGS PER DAY
3-4 SERVINGS PER DAY
4 + SERVINGS PER DAY
1 Serving = 1 slice Whole Grain Toast, 1/2 cup Whole Grain Pasta, cooked Oatmeal, 1 oz brown rice etc..
Dairy Intake - DAILY
*
Please Select
1 SERVING PER DAY
1-2 SERVINGS PER DAY
2-3 SERVINGS PER DAY
3-4 SERVINGS PER DAY
4 + SERVINGS PER DAY
1 Serving = 1 cup of Milk, Yogurt or Soy Milk (8oz), 1 cheese slice, 1.5 oz hard cheese, 1 cup cottage cheese etc.
Protein Intake Serving(s) WEEKLY
*
List a 5 day Sample Meals You Consume
*
List 5 day Sample of AM, PM or Midnight Snacks and Daily Liquids (Do not Include Water)
*
Percentage of Home Cooked Food per Week ?
*
Percentage is based on all your meals for 7 days.
List the top 3 Long Term/Permanent Change(s) you wish to make in your Life :
What are the 3 most important lifestyle goals you wish to implement?
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