Health History Form
Let's do a deeper dive into your lifestyle, wants, needs and commitment level
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Name 
Age
Address
Phone #
Email
Emergency Contact (Name + phone #)
Lifestyle Goals (check all that apply) *
Column 1
Feel More Vibrant
Get Better Sleep
Enhance Immunity
Transform Mindset
Increase Mental Clarity
Have More Energy
Gain Muscle
Loose Weight
Increase Confidence
Do you smoke *
Do you drink alcohol *
Sleep schedule (amount of hours and time) *
Describe your job *
Rate your stress level *
minimal
excessive
List your 3 biggest sources of stress *
Do you regularly utilize the services of a massage therapist? *
Required
Is anyone in your family overweight? *
Were you overweight as a child? And if so, what age? *
Do you have elevated LDL cholesterol levels? *
Required
Do you have elevated triglyceride levels? *
Required
What is your current height and weight? *
Typical blood pressure reading? *
Required
When was your last blood test? *
On your last blood test, was your fasting blood glucose above 100% ? *
Required
When were you in the best shape of your life? *
Have you been exercising consistently for the past 3 months? *
When did you first start thinking about getting in better shape? *
What, if anything, stopped you in the past from being in optimal health / physical fitness *
On a scale of 1-10, how would you rate your fitness level? *
worst
best
How often do you take part in physical exercise? *
If your participation is lower than you'd like it to be, what are the reasons? *
For how long have you been consistently physically active? *
What activities are you presently involved in? (note frequency & duration) *
Is cardio conditioning an area that you would like help with? *
Required
What types of cardio conditioning are you currently doing, if any (note frequency & duration) *
Is strength training an area that you would like help with? *
Required
How would you describe your current diet? *
How often do you eat per day? (note # of meals and snacks) *
Do you take supplements?  *
If currently on a nutritional regimen, please list supplements you're currently taking *
Do you have ay food allergies? If so, please list them. *
What time is your first meal of the day? *
What is the last time you eat something each day? *
What do you crave the most? *
If you could prioritize & improve up to 3 things about your health, what would they be? *
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