Confidential Health History Form

If you are contacting me to schedule your initial consultation, please fill out the health history form below. Select which program you are interested in and any additional comments or questions you may have. I look forward to speaking with you.

* Required Fields

Basic Information

* Client Name:
* Address:
* City:
* State:
* Zip:
* Email Address:
How often do you check email?
Telephone - Work:
Home:
Cell:
* Age:
* Height:
* Date of Birth:
Place of Birth:

Current Health and Lifestyle

Current weight:
Weight six months ago?
One year ago?
Would you like your weight to be different? Yes No If so, what?
Relationship status:
Children?
Occupation:
How many hours a week do you work?
Do you sleep well? Yes No
Do you wake up at nights? Yes No If so, what time(s)?
To urinate:
What time do you generally get up in the morning?
Do you experience constipation/diarrhea? Yes No If yes, please explain
What blood type are you?
What is your ancestry?
Do you take any supplements or medications? If so, which?
Are there any healers, helpers or therapies with which you are involved? Please list:
What role does exercise play in your life?
Do you drink coffee, smoke cigarettes, or have any major addictions?
What percentage of your food is home cooked?
Where do you get the rest from?
Serious illness / hospitalizations / injury
How is the health of your mother?
How is the health of your father?
What is your chief concern?
Other concerns?

Women

Are your periods regular? Yes No
How many days is your flow?
How frequent?
Painful or symptomatic? Yes No Please explain
Are you pregnant? Yes No
If yes, when's the due date?
Any special pregnancy concerns?
Any you breastfeeding?