Health History Form Submit a health history for a free initial 30 minute phone consultation to discuss your desired health goals and how I can help you achieve them. Name Email How often do you check email? Contact Number Date of Birth Place of Birth Age Height (CM) Current Weight (KG) Weight 6 months ago (KG) Weight 12 months ago (KG) Would you like your weight to be different? If yes, what? SOCIAL INFORMATION Relationship Status Where do you currently live? Children? (including age) Pets Occupation Hours of work a week HEALTH INFORMATION Blood Type (if known) Please list your main health concerns What are your health and wellness goals? At what point in your life did you feel best? Any serious illness, injuries or hospitalisations? Any pre-existing conditions currently being treated? What is/was the health of your mother? What is/was the health of your father? What is your ancestry? How is your sleep? include number of hours per night Do you wake at night? include number of times and why Any pain, stiffness or swelling? Do you experience any constipation, diarrhoea or gas? list how often Do you have any allergies or sensitive? Do you experience any acne? WOMEN'S HEALTH (leave blank for men) Are your periods regular? How many days is your flow and how frequent? Do you experience any pain or symptoms? Reached or approaching menopause? list any concerns or symptoms Birth Control history Do you experience any yeast infections or urinary infections? MEDICAL INFORMATION 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? Are you currently under the guidance or care from health practitioner? if yes, what for? FOOD INFORMATION What foods did you eat as a child? (list Breakfast, Lunch, Dinner, Snacks and Liquids) What foods do you eat now? (list Breakfast, Lunch, Dinner, Snacks and Liquids) Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? 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: ADDITIONAL COMMENTS
