Health History Form Please enable JavaScript in your browser to complete this form.Name: *FirstLastAge: *Date of Birth:Place of Birth:Email: *How often do you check your email? Phone: *Phone Type *CellHomeWorkCurrent Weight:Weight Six Months Ago:Weight One Year Ago:Would you like your weight to be different? If so, how? Relationship Status:SingleIn RelationshipMarriedDivorcedWidowedWhere do you live? Any children? Any pets? Occupation:How many hours per week do you work? What are your main health concerns? Do you have any other concerns or goals? At what point in your life did you feel your best? Any current or previous serious illnesses, hospitalizations, or injuries? How is/was your mother's health? How is/was your father's health? What is your ancestry? What is your blood type? How is your sleep?How many hours do you sleep per night? 0 to 4 hours4 to 6 hours6 to 8 hours> 8 hoursDo you wake up at night? If so, why? Do you have any pain, stiffness, or swelling? Do you have any constipation, diarrhea, or gas? Do you have any allergies or sensitivities? Are your periods regular? How many days is your flow? How frequent are your periods? Are your periods painful or symptomatic? If so, please explain.Have you reached or are you approaching menopause? If so, please explain.What is your birth control history? Do you experience yeast infections or urinary tract infections? If so, please explain. Please list all supplements or medications that you take. Are you involved with any healers, helpers, or therapies? What role do sports and exercise play in your life? Will your family and 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 does your non-home-cooked food come from? What foods did you eat often as a child (breakfast, lunch, dinner, snacks, and liquids)? What foods do you typically eat these days (breakfast, lunch, dinner, snacks, and liquids)? Do you crave sugar, coffee, or cigarettes. Do you have any other major addictions? What is the most important thing you should change about your diet to improve your health? Is there anything else you would like to share? WebsiteSubmit