Health History Intake All of your information will remain confidential. PERSONAL INFORMATION Name * First Name Last Name Gender: Pronouns: Height: Age: Birth Month: January February March April May June July August September October November December Birth Date: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year: Place of Birth: Current weight: Would you like your weight to be different? If so, how? CONTACT INFORMATION Home phone: Mobile Phone: Work Phone: Email Address * How often do you check your email? SOCIAL INFORMATION Relationship status: Where do you currently live? Children: Pets: Occupation: Hours of work per week: HEALTH INFORMATION Please list your main health concerns: Other concerns and/or goals? At what point in your life did you feel best? Any serious illness/hospitalization/injuries? How is/was the health of your mother? How is/was the health of your father? What is your ancestry? What blood type are you? How is your sleep? How many hours do you get? Do you wake up at night? Why? Any pain, stiffness or swelling? Constipation/Diarrhea/Gas? Allergies or sensitivities? Please explain: MONTHLY MOON CYCLE INFORMATION If applicable* Are your periods regular? How many days is your flow? Painful or symptomatic? Please explain: Have you reached, or are you approaching, menopause? Please explain: Birth control history: Do you experience yeast infections or urinary tract infections? Please explain: 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? FOOD INFORMATION What foods did you eat often as a child? Breakfast: Lunch: Dinner: Snacks: Liquids: What is your food like these days? Breakfast: Lunch: Dinner: Snacks: Liquids: Do you cook? 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: Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? ADDITIONAL COMMENTS Anything else you would like to share? Thank you!
