Health History Form Our journey together begins with your health story. Name * First Name Last Name Email * What are your health and wellness goals? Please list any supplements or medications you take: Medical diagnoses, history of serious illnesses, hospitalizations, injuries, or surgeries Do you have any other notable family or personal health information you’d like to share? PHYSICAL INFORMATION Current Weight Height How many hours on average do you sleep per night? How would you describe the quality of your sleep? How is your energy level most days? Very low, it's hard to get out of bed Just okay, I'll make it through the day with the help of caffine I have good days and bad days My energy levels are great Bursting with energy, unstoppable Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain Do you have any of the following concerns? Metabolic Health Blood Sugar Imbalances Elevated Cholesterol Elevated Blood Pressure Elevated Triglycerides Digestive Health Bloating Nausea Constipation Stomach Pain Diarrhea Gas Other if you selected "other" please explain Do you have regular bowel movements? Hell Yes :) Heck No :( Reproductive Health Infertility Irregular Menstrual Cycle Low Libido Hormonal Health Thyroid Condition Toxin Exposure Signs or Symptoms of Hormonal Imbalance Immune health Autoimmune Conditions Frequent Illness or Infection Low Vitamin D Level Allergies and Sensitivities (please list below) Brain Health Brain Fog Difficulty Concentrating Forgetfulness Migraines/Headaches NUTRITION INFORMATION What foods did you grow up eating? How would you describe your relationship with food? Are you a snacker? Emotional eater? Maybe you're a picky eater, let me know! Do you have any food allergies or intolerances? Do you follow a specific eating approach/practice for personal, health, or religious reasons (e.g., vegan, ketogenic, kosher)? What does a typical day of eating look like for you? Breakfast Lunch Dinner Snacky-snacks MENTAL AND EMOTIONAL HEALTH INFORMATION How would you describe your overall mental and emotional health? How do you cope with stress? You're almost done, stay with me! Using a 1–5 scale (where 1 = never and 5 = always), rate how often you experience each of the following: Anger 1 2 3 4 5 Fear 1 2 3 4 5 Stress 1 2 3 4 5 Joy 1 2 3 4 5 Love 1 2 3 4 5 Sadness 1 2 3 4 5 SPIRITUAL HEALTH INFORMATION What role does spirituality play in your life? LIFESTYLE INFORMATION What are the important relationships in your life? 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? Is there anything else you’d like to share? Thank you!
