Health History Form

Today's Date

Month Day Year

Your Name:

First Name Last Name

Cell Phone Number

Area Code Phone Number

Home Phone Number

Area Code Phone Number

Date Of Birth

Month Day Year

Height

Weight

Email

Are You Married or Do You Live With Your Partner? If Yes..For How Long?

Do You Have Children? If Yes...Age & Name of Children *

What is Your Occupation? If Yes, What Day's and Hours Do You Work? *

Hobbies - Passions - Interests *

Please List All Major Health Concerns and Symptoms In Order of Importance. You Can List as many as you need to. *

What major life events have occurred in the last 3 years? *

Have you been under any more stress than "usual" in the last 3 years? And, if "yes" what? *

What things do you typically do that help you manage stress? *

Which Types of Doctors and Practitioners Have You Been To In The Past? *

Describe The Treatments They Gave You and Whether or Not They Were Effective? *

When Is The Last Time You Really Felt Good? *

Were You Healthy As A Child? If Not, Please List Any Health Problems You Can Remember Having, Especially If They Were Chronic and/or Recurring. *

Do you feel there was 1 or Multiple TRIGGER EVENT(s) that contributed or led to your current symptoms/illness/diagnosis? If so, what were they? *

Have you ever been constipated? (less than 2 bowel movements daily) If so, for how long? *

Have you ever taken or done anything for constipation? (laxatives, enemas, etc.) *

Please list any and all surgeries you've had along with the Dates: *

Have you taken antibiotics more than 6 times in your life? What kinds of issues do you remember taking them for? *

Have you ever done any life-mapping strategies? If so, what have you done?

Do you have trouble falling asleep? If So when do you remember first having trouble? *

Do you have trouble staying asleep? If So when do you remember first having trouble? *

How do you feel when you first wake up? (well-rested, still tired, achy, nauseous, etc.) *

Please list ALL medications you are CURRENTLY taking, along with the dosage, how often, and for how long: *

What symptoms, if any, do you feel are side effects of the medications? *

Please List ALL Supplements you are currently taking, including the brand names, how much of each, and how often: *

How many alcoholic drinks do you have each day? Or the total for each week? What are your drinks of choice? *

How many caffeinated beverages do you drink and which ones do you drink, how many each day and what do you put in your drinks? *

Do you eat out during the week? If so, how many times a week and what do you usually eat? *

How many times a week do you work out? What exercises do you typically do? For how long do you workout? *

Please List the 10 Most Un-Healthy Foods (what you deem to be the worst) You Eat Each Day/Week. Please put the foods you feel guilty about eating (if any) or the ones that you know don't make you feel great. The more details the better. :) *

Please List the 10 Healthiest Foods You Eat Each Day/Week. *

Please List an Average Day's Meals and Drinks and What Time. *

What are Your Top Health Goals for the next 12 months? *

Please put anything else here that you want to tell me or talk about when we speak. *