Health History Form If you are human, leave this field blank. Personal Information First Name Last Name Email Address Phone Number Age and birthday Height Current Weight Weight six months ago Weight one year ago Would you like your weight to be different? If so, what? Social Information Relationship status Do you have any children? Do you have any pets? Where were you born? Where do you currently live? Occupation Hours of work per week Health Information Please list your main health concerns Other concerns and/or goals? Please list any serious illnesses, injuries, or hospitializations: Current medications and/or supplements: What time in your life have you felt your best? How was/is the health of your parents? What is quality of your sleep? How many hours do you average per night? Any pain, stillness, sore joints? Any constipation, diarrhea, gas, or bloating? Any allergies? Describe your diet growing up: Describe your diet now: (typical breakfast. lunch, dinner, snacks, drinks) What percentage of your meals are cooked at home? Do you have any sugar, cigarette, coffee cravings or any major addictions? Do you have any healers, alternative practioniers, or regular self-care activities you are involved with? Please List. Anything else you'd like to share? What is the most important thing you could do to improve your health? reCAPTCHA
