Health History Intake Questionnaire
All of your information will remain confidential between you and myself, Lacey Maloney.
Personal Information
Full Name
*
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
How would you like to connect for our session(s)?
*
Telephone
Zoom
Place of Birth
Age
Height
Current Weight
Has your weight changed in the last 6 months? Last 12 months?
Are you satisfied with your current weight? If no, what would you like it to be?
Social Information
Relationship Status
Where do you currently live?
Occupation & how many hour per week do you work?
Children?
Yes
No
Pets?
Yes
No
Health Information
Please list your main health concerns
Any pain, stiffness or swelling?
Any chronic digestive issues: gas, diarrhea, indigestion, bloating, heartburn, ulcers, etc?
Allergies or sensitivities? Please explain:
What is your stress level like and how do you manage it?
Other concerns and/or goals?
For Women: How is your menstrual cycle?
Regular
Irregular
Approaching Menopause
Reached Menopause
For Women: Painful or symptomatic cycles? Please explain:
For Women: Do you experience yeast or urinary tract infections?
Any serious illnesses, hospitalizations, or injuries?
How is/was the health of your mother?
How is/was the health of your father?
How well do you sleep? How many hours? Do you wake up at night?
Medical Information
Do you take any medications? Please list here:
Do you take any supplements? Please list type, brand and dosage
Any healers, helpers or therapies with which you are involved? Please list:
What role do sports and exercise play in your life?
Food Information
What foods you you eat often? Please list:
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? How much of the food you eat is home cooked?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any addictions?
The most important thing I should do to improve my health is:
Any additional comments you would like to add:
Submit
Should be Empty: