Health History Form
Personal Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
County
Postcode
Gender Identity
Occupation
Emergency Contact Details
Health and Wellness Goals
What are your health and wellness goals? Why are they important to you?
Personal Health and Family History
What’a the most important thing you’d like to share about your health story?
Please provide details if you have any of the following: primary care provider, physicians or specialists, practitioners, therapists, healers etc.
Please list any supplements or medication you take
Have you experienced any barriers or challenges to accessing healthcare?
Do you have any medical diagnoses or conditions, or history of serious illnesses, hospitalisations, injuries or surgeries
Describe the health of your parents
Is there anything from your childhood pertaining to your health you’d like to share?
Do you have any other notable family or personal health information you’d like to share?
Physical Health Information
Current height and weight
How many hours sleep per night on average?
How would you describe your quality of sleep?
How is your energy level most days?
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
Do you have any of the following concerns? (Check all that apply)
Blood sugar imbalances
Elevated cholesterol
Elevated triglycerides
Elevated blood pressure
Bloating
Constipation
Gas
Nausea
Infertility
Irregular menstrual cycle
Low libido
Thyroid condition
Signs of hormonal imbalance
Autoimmune conditions
Frequent illness or infection
Low vitamin D
Allergies
Brain fog
Difficulty concentrating
Forgetfulness
Nutritional Information
What foods did you grow up eating?
How would you describe your past relationship or history with food? Do any specific memories about food or eating come to mind?
Describe your current relationship with food
Do you have any food allergies or intolerances?
Do any of the following apply to you?
Challenges preparing meals
Challenges with access to food
Difficult chewing or swallowing
Poor appetite
Do you regularly use any of the following?
Alcohol
Tobacco
Other substances
Do you follow a specific eating approach/practice for personal, health or religious reasons eg vegan, ketogenic. If so please explain
What does a typical day of eating look like for you? List a few foods/meals and drinks you usually consume for breakfast, lunch, dinner and snacks
What if anything would you like to change about your nutrition?
Mental and Emotional Health Information
How would you describe your overall mental and emotional health?
How do you like to support your mental health?
How do you cope with stress?
Using a 1-5 scale (1 = never and 5 = always), rate how often you experience each of the following
Rows
1
2
3
4
5
Anger
Excitement
Fear
Joy
Love
Sadness
Stress
Worry
Spiritual Health Information
What role does spirituality play in your life, if any?
Lifestyle Information
What are the important relationships in your life?
Is there anything you would like to share about your social life?
Who do you live with if anyone?
How many hours per week do you typically work?
What hobbies or recreational activities do you enjoy?
What role does movement, including sports, exercise and physical activity play in your life?
Additional Comments
Is there anything else you’d like to share?
Submit
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