Forms “It was character that got us out of bed, commitment that moved us into action, and discipline that enabled us to follow through.” — Zig Ziglar Women's Health History Form Women's Health History Personal Name * First Name Last Name Age Height Date of Birth Place of Birth Email * How often do you check your email? Phone Number Current Weight Weight Six Months Ago Weight One Year Ago Would you like your weight to be different? If so, how? Social Relationship Status Where do you live? Any children? Occupation How many hours do you work per week? General Health What are your main health concerns? Any other concerns and/or goals? At what point in your life did you feel your best? Any current or previous serious illnesses, hospitalizations, or injuries? How is/was your mother's health? How is your father's health? What is your ancestry? What is your blood type? How is your sleep? How many hours do you sleep per night? Do you wake up during the night? If so, why? Any pain, stiffness, or swelling? Any constipation, diarrhea, or gas? Any allergies or sensitivities? Women's Health Are your periods regular? How many days is your flow? How frequent? Are your periods painful or symptomatic? if so, please explain Have your reached or are you approaching menopause? if so, please explain What is your birth control history? Do you experience yeast infections or urinary tract infections? if so, please explain Medical List all supplements or medications Are you involved with any healers, helpers, or therapies? What role do sports and exercise play in your life? Food Will your family and 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 does your non-home-cooked food come from? What foods did you eat often as a child? Breakfast/Lunch/Dinner/Snacks/Liquids What foods do you typically eat these days? Breakfast/Lunch/Dinner/Snacks/Liquids Do you crave sugar, coffee, or cigarettes? Do you have any other addictions? What is the most important thing you should change about your diet to improve your health? Additional Comments Is there anything else you would like to share? Thank you for completing the form. After review, I will be in contact as soon as possible to discuss our next steps. Men's Health History Men's Health History Form Personal Name First Name Last Name Age Height Date of Birth Place of Birth Email How often do you check your email? Phone Number Current Weight Weight Six Months Ago Weight One Year Ago Would you like your weight to be different? if so, how? Social Relationship Status Where do you live? Any children? Any pets? Occupation How many hours do you work? General Health What are your main health concerns? Any other concerns and/or goals? At what point in your life did you feel your best? Any current or previous serious illnesses, hospitalizations, or injuries? How is/was your mother's health? How is/was your father’s health? What is your ancestry? What is your blood type? How is your sleep? How many hours do you sleep per night? Do you wake up during the night? If so, why? Any pain, stiffness, or swelling? Any constipation, diarrhea, or gas? Any allergies or sensitivities? Medical List all supplements or medications Are you involved with any healers, helpers, or therapies? What role do sports and exercise play in your life? Food Will your family and 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 does your non-home-cooked food come from? What foods did you eat often as a child? What foods do you typically eat these days? Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions? What is the most important thing you should change about your diet to improve your health? Additional Comments Is there anything else you would like to share? Thank you for completing the form. After review, I will be in contact as soon as possible to discuss our next steps. Revisit Form Revisit Form Personal Information Name * First Name Last Name Date MM DD YYYY Email * Health Information What positive changes have you noticed since your last session? What are your main concerns at this time? Any changes with weight? How is your sleep? Constipation or diarrhea? How is your mood? Food Information Are you cooking more? What foods do you crave? Thank you for submitting this form! I’m looking forward to our next session together.
