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Health History
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Email
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Your email
Re: Email Address
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Name
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Address
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Phone #
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Age
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Pronouns
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Birthday
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MM
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DD
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YYYY
Place of Birth
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Where do you live now?
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Relationship Status
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Occupation
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Hours of work per week
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Height
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Weight
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Main causes of stress in your life
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What are your main health concerns?
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At what point in your life did you feel the best and why?
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Any serious illness/hospitalizations/injuries?
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How is/was the health of your father?
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How is/was the health of your mother?
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Were you born vaginally or c-section?
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What is your ancestry?
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What is your blood type?
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Do you have allergies/sensitivities?
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How is your sleep?
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How many hours of sleep per night?
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Do you wake up at night/ why?
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If you menstruate, how is your cycle overall?
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Do you experience pain or PMS?
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Birth control history + practice
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What supplements/medications do you take regularly?
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How are your energy levels throughout the day?
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How is your digestion / bowel movements?
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Do you suffer from regular pain?
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What is your relationship with your body like?
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What is your exercise or movement routine?
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Do you experience food cravings, if so, what kinds of food do you crave?
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Do you classify under a specific dietary theory?(ie; vegetarian, vegan, paleo, etc.)
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Do you cook at home? If so, what do you typically cook?
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How often do you cook at home?
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What were your meals like as a kid?
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What is an average day of eating like for you now?
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What liquids do you take in daily / How much?
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Alcohol or drug consumption / How much?
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What is one thing that you could do today to change your health?
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Do you currently take part in any form of healing or therapy?
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How do you want to feel?
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Is there a topic you would like to not be asked about?
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Anything else that you would like to share?
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How did you hear about my work?
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