New Client Health History
Please complete form. You are helping me to help you!
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Best phone # to contact
Hours worked per week
Recent Major Life Events/ Changes
Please list your main health concerns
Please list other concerns, goals, or aspirations
Quality of sleep:
Please list other health practitioners or healers you’re currently seeing, such as doctors, therapists, massage, etc. (Name/Specialty)
Rate your energy level on a scale from 1-5 (1 being low and 5 being high)
Level of physical activity:
What type? Examples: walking, swimming, gardening, weights, yoga, sports, other recreation
Nutrition and Wellbeing
Typical breakfast foods
Typical lunch foods
Typical dinner foods?
Typical snack foods and how often
Liquids you drink
Do you have any nagging cravings, such as tobacco, sugar, coffee or have major addictions?
Do you have episodes of eating excess junk foods, binge eating, yo-yo or continuous dieting?
What % of your meals are home-cooked?
What other types of food do you eat? Take out-where?
Are you currently on a special diet or avoid certain types of food? If yes, explain:
The most important thing I should do to improve my overall wellbeing
Please indicate if you have or had any of the following conditions:
Heart Disease/High Blood Pressure/High Cholesterol
Frequent Yeast Infections
Depression or Anxiety
Emotional Eating disorder
Anything else you would like to share?
Should be Empty: