Health HistoryPlease fill out as much as you can in the sections that are relevant for you. The more information you can share, the better! Name * First Name Last Name Email * Age Height Phone number Would you like your weight to be different? If so, how? Relationship Status (single, married, engaged...) Where do you live? Any children and/or pets? How often do you spend time with friends ? Occupation: How many hours a week do you work? What are your main health concerns? What are you goals? (Health and/or otherwise) At what point in your life did you feel your best? What were you doing then? Any current or previous serious illnesses, hospitalizations, or injuries? How is / was your mother's health? How is / was your father's health? How is your sleep? How many hours do you get a night on average? Do you wake up during the night? If so, why? Do you have any pain, stiffness, or swelling? Any constipation, diarrhea, or gas? Any allergies or sensitivities? For those who have periods: are your periods regular? How many days is your flow? How frequent? Are your periods painful or symptomatic? If so, please explain: Have you reached or are you approaching menopause? 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: 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? Do you have any cravings? 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? Thank you!
