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Health History
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*
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Personal Information
First Name
*
Last Name
*
Email
*
Birth Date
Month
Day
Year
Age
Please enter a number from
18
to
110
.
Sex Assigned at Birth:
*
Gender Identity:
Preferred Pronouns:
Occupation:
Best Number to Reach you at.
*
Phone - please use country code if outside the US +1 (xxxx) xxx-xxxx
Preferred Contact Method:
*
Phone
Text
Email
Mail
Emergency Contact Name:
Relationship:
Emergency Contact Phone:
Health and Wellness Goals
What are your health and wellness goals? Why are they important to you?
Personal Health and Family History
What’s the most important thing you’d like to share about your health story?
• Primary care provider:
• Other physicians or specialists:
• Practitioners, therapists, healers, etc.:
Please list any supplements or medications you take:
Have you experienced any barriers or challenges to accessing healthcare?
Do you have any of the following? If so, please list.
• Medical diagnoses or conditions:
• History of serious illnesses, hospitalizations, injuries, or surgeries:
Describe the health of your:
Mother
Father
Is there anything from your childhood pertaining to your health you’d like to share?
Physical Health Information
Current Weight:
Height:
• How many hours do you sleep per night on average?
• How would you describe your quality of sleep?
How is your energy level most days?
1 (Very Low)
2
3
4
5 (Very High)
Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain:
Metabolic health
Blood Sugar Imbalances
Elevated Blood Pressure
Elevated Cholesterol
Elevated Triglycerides
Other:
Other metabolic health
Digestive health
Bloating
Constipation
Diarrhea
Nausea
Stomach Pain
Gas
Other
Other Digestive Health
How many bowel movements (on average) do you have per day?
Reproductive health
Irregular Menstrual Cycle
Infertility
Low Libido
Difficulty Orgasming
Premature Ejaculation
Erectile Dysfunction
Other
Other Reproductive Health
Hormonal health
Toxin Exposure
Thyroid Condition
Other:
Other Hormonal Health
Immune health
Autoimmune Conditions
Low Vitamin D Level
Frequent Illness or Infection
Allergies and Sensitivities (please list)
Other:
Other Immune Health
Sensitivities & Allergies list
Brain health
Brain Fog
Difficulty Concentrating
Forgetfulness
Other:
Other Brain Health
Nutrition Information
What foods did you grow up eating?
How would you describe your past relationship or history with food?
Do any specific memories about food or eating come to mind?
Describe your current relationship with food.
Do you have any food allergies or intolerances? If so, please list:
Do any of the following apply to you? (Check all that apply.)
Challenges with Preparing Meals
Poor Appetite
Challenges with Access to Food
Difficulties Chewing or Swallowing
Select All
Do you regularly use any of the following? (Check all that apply.)
Alcohol
Tobacco Products
Other Substances
Select All
Other substances
Do you follow a specific eating approach/practice for personal, health, or religious reasons (e.g., vegan, ketogenic, kosher)? If so, please explain:
Breakfast
Lunch
Dinner
Snacks
What, if anything, would you like to change about your nutrition?
Mental and Emotional Health Information
How would you describe your overall mental and emotional health?
How do you like to support your mental health?
How do you cope with stress?
Anger
Please enter a number from
1
to
5
.
Excitement
Please enter a number from
1
to
5
.
Fear
Please enter a number from
1
to
5
.
Joy
Please enter a number from
1
to
5
.
Love
Please enter a number from
1
to
5
.
Sadness
Please enter a number from
1
to
5
.
Stress
Please enter a number from
1
to
5
.
Worry
Please enter a number from
1
to
5
.
Spiritual Health Information
What role does spirituality play in your life, if any?
Lifestyle Information
What are the important relationships in your life?
Is there anything you’d like to share about your social life? If so, please explain:
Who do you live with, if anyone?
How many hours per week do you typically work?
What hobbies or recreational activities do you enjoy?
What role does movement, including sports, exercise, and physical activity, play in your life?
Addtional Comments
Is there anything else you’d like to share?
Comments
This field is for validation purposes and should be left unchanged.
"
*
" indicates required fields
Personal Information
First Name
*
Last Name
*
Email
*
Birth Date
Month
Day
Year
Age
Please enter a number from
18
to
110
.
Sex Assigned at Birth:
*
Gender Identity:
Preferred Pronouns:
Occupation:
Best Number to Reach you at.
*
Phone - please use country code if outside the US +1 (xxxx) xxx-xxxx
Preferred Contact Method:
*
Phone
Text
Email
Mail
Emergency Contact Name:
Relationship:
Emergency Contact Phone:
Health and Wellness Goals
What are your health and wellness goals? Why are they important to you?
Personal Health and Family History
What’s the most important thing you’d like to share about your health story?
• Primary care provider:
• Other physicians or specialists:
• Practitioners, therapists, healers, etc.:
Please list any supplements or medications you take:
Have you experienced any barriers or challenges to accessing healthcare?
Do you have any of the following? If so, please list.
• Medical diagnoses or conditions:
• History of serious illnesses, hospitalizations, injuries, or surgeries:
Describe the health of your:
Mother
Father
Is there anything from your childhood pertaining to your health you’d like to share?
Physical Health Information
Current Weight:
Height:
• How many hours do you sleep per night on average?
• How would you describe your quality of sleep?
How is your energy level most days?
1 (Very Low)
2
3
4
5 (Very High)
Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain:
Metabolic health
Blood Sugar Imbalances
Elevated Blood Pressure
Elevated Cholesterol
Elevated Triglycerides
Other:
Other metabolic health
Digestive health
Bloating
Constipation
Diarrhea
Nausea
Stomach Pain
Gas
Other
Other Digestive Health
How many bowel movements (on average) do you have per day?
Reproductive health
Irregular Menstrual Cycle
Infertility
Low Libido
Difficulty Orgasming
Premature Ejaculation
Erectile Dysfunction
Other
Other Reproductive Health
Hormonal health
Toxin Exposure
Thyroid Condition
Other:
Other Hormonal Health
Immune health
Autoimmune Conditions
Low Vitamin D Level
Frequent Illness or Infection
Allergies and Sensitivities (please list)
Other:
Other Immune Health
Sensitivities & Allergies list
Brain health
Brain Fog
Difficulty Concentrating
Forgetfulness
Other:
Other Brain Health
Nutrition Information
What foods did you grow up eating?
How would you describe your past relationship or history with food?
Do any specific memories about food or eating come to mind?
Describe your current relationship with food.
Do you have any food allergies or intolerances? If so, please list:
Do any of the following apply to you? (Check all that apply.)
Challenges with Preparing Meals
Poor Appetite
Challenges with Access to Food
Difficulties Chewing or Swallowing
Select All
Do you regularly use any of the following? (Check all that apply.)
Alcohol
Tobacco Products
Other Substances
Select All
Other substances
Do you follow a specific eating approach/practice for personal, health, or religious reasons (e.g., vegan, ketogenic, kosher)? If so, please explain:
Breakfast
Lunch
Dinner
Snacks
What, if anything, would you like to change about your nutrition?
Mental and Emotional Health Information
How would you describe your overall mental and emotional health?
How do you like to support your mental health?
How do you cope with stress?
Anger
Please enter a number from
1
to
5
.
Excitement
Please enter a number from
1
to
5
.
Fear
Please enter a number from
1
to
5
.
Joy
Please enter a number from
1
to
5
.
Love
Please enter a number from
1
to
5
.
Sadness
Please enter a number from
1
to
5
.
Stress
Please enter a number from
1
to
5
.
Worry
Please enter a number from
1
to
5
.
Spiritual Health Information
What role does spirituality play in your life, if any?
Lifestyle Information
What are the important relationships in your life?
Is there anything you’d like to share about your social life? If so, please explain:
Who do you live with, if anyone?
How many hours per week do you typically work?
What hobbies or recreational activities do you enjoy?
What role does movement, including sports, exercise, and physical activity, play in your life?
Addtional Comments
Is there anything else you’d like to share?
Phone
This field is for validation purposes and should be left unchanged.
