Health History Form
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This is a form for new clients.
For existing clients, please fill out the Client Re-Visit Form.
Name Date
Email Times/day check email?
Phones:
Home Work
Cell
Address City
State Zip
Age Height
Birth Date Place
Sex
Current Weight Weight 6 mos. ago
1 yr. ago
What would you like your weight to be?
Single Married Divorced Children
Occupation Hours/
week
Do you sleep well? Yes No Wake up during the night? Yes No
What time? To urinate? Yes No
What time do you generally get up in the morning?
Do you experience constipation/diarrhea?
Blood type Racial ancestry?
WOMEN:
Are your periods regular? Yes No How many days is your flow?
How frequent? Painful or symptomatic?
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 / injuries:
Mother's health? Father's health?
What is your chief concern?
Other concerns?
What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snacks
Liquids
What about one year ago?
Breakfast
Lunch
Dinner
Snacks
Liquids
What's your food like these days?
Breakfast
Lunch
Dinner
Snacks
Liquids