Health Form

First Name *

First Name

Last Name *

Last Name

Email Address *

Email address

How often do you check email?

Home Phone

Work phone

Cell phone

Age

Height

Birthdate

Place of birth

Current weight

Weight 6 months ago?

One year ago?

Would you like your weight to be different? If so, what?

Relationship status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week

Please list your main health concerns

Any pain, stiffness or swelling?

Any other concern and/or goals?

Constipation/Diarrhea/Gas?

At what point in your life did you feel best?

Allergies or sensitivities? Please explain.

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

What blood type are you?

Reached or approaching menopause? Please explain.

How is your sleep?

Birth control history

How many hours?

Do you experience yeast infections or urinary tract infections? Please explain.

Do you wake up at night? Why?

Do you take any supplements or medications? Please list.

Any healers, helpers or therapies with which you are involved? Please list.

What role do sports and exercise play in your life?

What is a typical day of eating like for you?

Breakfast

Lunch

Dinner

Snacks and Liquids

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

Do you cook?

What percentage of your food is home-cooked?

Where do you get the rest from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

The most important thing I should do to improve my health is –

Anything else you would like to share?

Recent Posts

Follow Be Well Nourished!

Sign Up for Recipes and Inspiration!