Health History Form
Would you like your weight to be different?
If so, what?
Please list your main health concerns:
Any serious illnesses/hospitalizations/injuries?
How is your sleep?
How many hours?
Do you wake up at night?
Any pain, stiffness, or swelling?
Allergies or food sensitivities? If so, please explain:
Are your periods regular?
How many days is your flow?
Painful or symptomatic? Please explain:
Reached or approaching menopause?
Birth control history:
Do you experience yeast infections or urinary tract infections? Please explain:
Do you take any supplements or medications? Please list:
Any healers, helpers, or therapies with which you are involved? Please list:
What role do sports/exercise play in your life?
What is your food like these days?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?
What percentage of your food is home-cooked?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is:
How would you describe your current relationship with food?
Anything else you would like to share?
Should be Empty:
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