Health History Form

Health History Form

Qi Wellness Collective
Full Name
Date of Birth

MonthDayYear
Date
Age
Gender
Pronouns
Occupation
Email
example@example.com
Phone
Home Address
Emergency Contact Name
Relationship
Phone
What are your health and wellness goals?
Whats the most important thing youd like to share about your health story
Primary care provider
Other physicians or specialists
Practitioners therapists healers etc
Please list any supplements or medications you take
Have you experienced any barriers or challenges to accessing healthcare
Medical diagnoses or conditions
History of serious illnesses hospitalizations injuries or surgeries
Have you been Vaccinated for Covid? If yes please write which type and amount of boosters
Is there anything from your childhood pertaining to your health youd like to share
Do you have any other notable family or personal health information youd like to share
Current Weight
Height
How many hours do you sleep per night on average
How would you describe your quality of sleep
How is your energy level most days?
Do you experience any pain stiffness or swelling on a regular basis If so please explain
How many bowel movements on average do you have per day
NUTRITION 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 If so please list
Do any of the following apply to you? (Check all that apply

Challenges with Preparing MealsChallenges with Access to FoodDifficulties Chewing or SwallowingOvereatingEmotional EatingEating while doing other activitiesFeeling Bloated after a Meal
Do you follow a specific eating approachpractice for personal health or religious reasons eg vegan ketogenic kosher 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 in the corresponding categories:
Breakfast
Lunch
Dinner
Snacks
What if anything would you like to change about your nutrition
Mental and Emotional Wellness
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
What role does spirituality play in your life if any
What are the important relationships in your life
Is there anything youd like to share about your social life If so please explain
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
Have you ever worked with Visionary Plant Medicines or Compounds? If so which ones and experiences. If no are you interested?
Is there anything else youd like to share
Should be Empty:

Health History Form

NUTRITION INFORMATION