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Nutrition, Health & Wellness Health History
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Email
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Your email
Name
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Your answer
How often do you check email?
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Your answer
Telephone number
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Age
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Your answer
Height
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Your answer
Current weight
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Your answer
Weight 6 months ago
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Your answer
Weight one year ago
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Your answer
Would you like your weight to be different? If so, how?
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Your answer
Relationship status
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Your answer
Children:
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Your answer
Pets
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Your answer
Occupation; hours/week
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Your answer
Please list your health concerns:
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Your answer
Other concerns:
Your answer
Do you sleep well?
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Your answer
How many hours/night?
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Your answer
Do you wake up at night?
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Your answer
If so, why do you wake up at night?
Your answer
Any pain, stiffness or swelling?
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Your answer
Constipation/diarrhea/gas? If yes, explain
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Your answer
Do you take any supplements or medications? If yes, what?
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Your answer
What role does exercise/movement play in your life?
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Your answer
What foods did you eat often as a child (in each category below)?
Breakfast
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Your answer
Lunch
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Your answer
Dinner
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Your answer
Snacks
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Your answer
Liquids
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Your answer
What is your food like these days (in each category below)?
Breakfast
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Your answer
Lunch
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Your answer
Dinner
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Your answer
Snacks
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Your answer
Liquids
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Your answer
What percentage of your food is home-cooked?
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Your answer
Do you cook?
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Yes
No
Where do you get the rest from?
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Your answer
Do you crave sugar, coffee, cigarettes, or have any major addictions?
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Your answer
Anything else you would like to share?
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Your answer
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