Health Form Step 1 of 7 14% Name First Last Are you Male or FemalePlease choose sexMaleFemaleEmail How often do you check email? Phone (Home)Phone (Work)Phone (Mobile)Age Height Birthdate Place of Birth Current Weight Weight six month ago Weight one year ago Would you like your weight to be different?YesNoIf so, what? Social InformationRelationship Status Where do you currently live? Children Pets Occupation Hours of work per week Health InformationPlease list your main health concerns Other concerns and /or goals? At what point in your life did you feel best? Any serious illnesses/ hospitalization/ injuries? How is / was the health of your mother? How is / was the health of your father? What is your ancestry? How is your sleep? How many hours? Do you wake up at night? Why?Any pain, stiffness, or swelling? Constipation/Diarrhea/Gas? Allergies or sensitivities? Please explain: Women's HealthAre your periods regular? How many days is your flow? How frequent? Painful or symptomatic? Please explainReached or approaching menopause? Please explain:Birth control history: Do you experience yeast infections or urinary tract infections? Please explain Medical InformationDo you take any supplements or medications? Please list: Any healers, helpers, or therapies with which you are involved? Please list: What role do sports and exercise play in your life? Food InformationWhat foods did you eat often as a child?BreakfastLunchDinnerSnacksLiquids What is your food like these days?BreakfastLunchDinnerSnacksLiquids 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: ADDITIONAL COMMENTSAnything else you would like to share? Δ
