Health History Form
(Click here to close this form.)
Today's Date:
Your Name:
Address:
City:
State: Zip:
Email Address:
How often do you check email?
Telephone -
Work:
Home:
Cell:
Age:
Height:
Date of Birth:
Place of Birth:
Current weight:
Weight six months ago? One year ago?
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Would you like your weight to be different?
If 'Yes", what would you like it to be?
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Relationship status:
Children?
Occupation:
How many hours a week do you work?
Do you sleep well?
Do you wake up at nights?
If 'Yes' what time(s) do you wake up?
What time do you generally get up in the morning?
To urinate:
Do you experience constipation/diarrhea?
If yes, please explain
What blood type are you?
What is your ancestry?
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Women:
Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic?
If 'Yes', please explain:
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Do you take any vitamins/medications? If so, which?
Are there any other healers, helpers, pets, 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 / injury
How is the health of your mother?
How is the health of your father?
What is your main health concern?
If you have any other concerns, please let me know?
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What foods did you eat often as a child?
breakfast
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lunch
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dinner
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snacks
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liquids
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What about one year ago?
breakfast
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lunch
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dinner
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snacks
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liquids
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What are the food you like to eat these days?
breakfast
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lunch
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dinner
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snacks
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liquids
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