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Health History
Institute for Integrative Nutrition
Please answer the questions below. All of your information will remain confidential.
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Personal Information
First and last name
Your answer
E-mail
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How often do you check e-mail?
Your answer
Phone number
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Age
Your answer
Height
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Birthdate
MM
/
DD
/
YYYY
Place of birth
Your answer
Current weight
Your answer
Weight 6 months ago
Your answer
Weight one year ago
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Would you like your weight to be different? If so, what?
Your answer
Would you like your weight to be different?
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Social Information
Relationship status
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Where do you currently live?
Your answer
Children:
Your answer
Pets:
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Occupation:
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How many hours per week?
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Health Information
Please list your main health concerns:
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Other concerns and/or goals
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At what point in your life did you feel best?
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Any serious illnesses/ hospitalizations / injuries?
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How is/was health of your mother?
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How is/was health of your father?
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How is/was health of your father?
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What is your ancestry?
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What blood type are you?
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How is your sleep?
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How many hours of sleep?
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Do you wake up at night? If so, why?
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Any pain, stiffness, or swelling?
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Constipation/Diarrhea/Gas?
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Allergies or sensitivities? Please explain:
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Medical Information
Do you take any supplements or medications? Please list:
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Any healers, helpers, or therapies with which you are involved? Please list:
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What role does sports and exercise play in your life?
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Food Information
What foods did you eat often as a child? Option to fill out breakfast, lunch, dinner, liquids, and snacks here or below:
Your answer
Breakfast
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Lunch
Your answer
Dinner
Your answer
Snacks
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Liquids
Your answer
What is your food like these days? Breakfast, lunch, dinner, liquids, and snacks, option to fill out each one in the questions below:
Your answer
Breakfast
Your answer
Lunch
Your answer
Dinner
Your answer
Snack
Your answer
Liquids
Your answer
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
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Do you cook?
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What percentage of the food is home-cooked?
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Where do you get the rest from?
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Do you crave sugar, coffee, cigarettes, or have any major addictions?
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The most important thing I should change about my diet to improve my health is:
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Additional Comments
Anything else you would like to share?
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