Confidential Health History Date: Client Contact Information Referred By First name Middle name Last name Home address 1 Home address 2 City/State/Zip Cellular phone Home and/ or Work phone Email Address Method of contact preferred
Basic Statistics/History Age Birth Date/Place of Birth Relationship status Children? Will your family/friends be supportive of your desire to make food/and or lifestyle changes? Pets? Occupation and number of hours you work per week How many days have you taken off from work in the last year? Have you or your family recently experienced any major life changes?
Have you experienced any major losses in life?
Health History Please circle any of the following conditions that apply to your history Cancer
Heart Disease
Menopause
Acute/chronic pain
Metabolic Syndrome
Acute/chronic stress
Migraine/headaches
Alcohol/drug addiction
Lupus
Arthritis or Rheumatoid arthritis
High Blood Pressure
Chronic Fatigue
High Cholesterol
Hepatitis
Kidney Disease
Venereal Disease
Thyroid Disease
Osteopenia/Osteoporosis
Depression
Fibromyalgia
Asthma
Diabetes Type 1 or Type 2
Allergies Food or Allergies Seasonal
Low Blood Pressure
Anemia
Memory Loss
Chronic Yeast Infections
Snoring
Other
Sinus Problems
List your main health concerns and/or goals.
Have other family members had similar health concerns?
Please list all health practitioners you are currently seeing for these health concerns (doctors, massage therapists, naturopaths, chiropractic, etc.) or for routine health checks
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Please list the year of your most recent tests as applicable:
Bone density Cardiac stress test Colonoscopy Flu Shot Genetic labs Nutritional labs Mammogram Pap Smear Tetanus Shot Other:
Please list all medicine you are currently taking (over the counter and prescription) and for which condition:
Please list all vitamins, minerals, herbs and nutritional supplements you are currently taking:
Height Birth Weight Current Weight Weight 6 months ago Weight one year ago Ideal Weight if different from current weight Blood type if known – A, B, O Ancestry (German, Italian, Mexican, etc.) How is/was the health of your mother?
How is/was the health of your father?
Known food allergies or sensitivities: Known seasonal allergies and current treatment: 3
Are there any foods that you avoid because of how they make you feel? If yes, describe the symptoms. Do you experience bloating, gas, sneezing or hives immediately after eating? If yes, please describe. Are you aware of any delayed symptoms after eating certain foods such as sinus congestion, fatigue, or muscle aches? Do you crave any specific foods? What? Which of these foods do you consume regularly? Please circle Are you currently on a special diet? (Ovo-lacto, diabetic, dairy restricted or dairy fee, vegetarian, vegan, paleo, blood type, raw, gluten-free, etc) What percentage of your meals are cooked at home? Please describe one breakfast, lunch or dinner you might make at home.
Soda Diet Soda (wheat, rye, barley)
Refined sugar alcohol dairy coffee
Percentage Breakfast Lunch Dinner
When you eat out, where do you go?
How frequently do you have a bowel movement? Please circle one How many times have you taken antibiotics in your life? Why? Have you been exposed to chemicals on a regular basis or to toxic metals?
1-3 times per day more than 3 times per day not regularly every day
Do odors affect you? Do you smoke or are you or have you been exposed to second-hand smoke? Do you have mercury amalgam fillings? What role do sports and exercise play in your life?
Reproductive Health (WOMEN) How are/were your menses? Do/did you have PMS? Please describe
Have you/do you take birth control pills? If so, list length of time and type Difficulty with conception or pregnancy? Please describe any replacement therapy or hormonal supportive herbs 4
fast food
gluten
Mental Health How are your moods in general? Do experience more anxiety, depression, or anger than you would like?
Describe your energy level throughout the day and what you do to improve it.
Do you have a spiritual connection?
Additional Information Is there anything else you want to share that would be useful in helping to address your health concerns?
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