Health History intake form Full Name * First Name Last Name Date of Birth * MM DD YYYY Age * Gender Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * Relationship * Contact's Phone * (###) ### #### List three of your health and wellness goals * WHAT MAKES THESE GOALS IMPORTANT TO YOU IN YOUR HEALTH JOURNEY? * WHERE ARE YOU WITH THESE GOALS TODAY? RANK 1-10 * (1 = low, 10 = high) What are you currently doing that supports your goals: * WHAT DO YOU SEE AS OBSTACLES IN ORDER TO ACHIEVE THESE GOALS? * tell me a little bit about your journey so far...have you seen any doctors? therapists? specialists? etc... * list any supplements and/or medications you currently take: * do you or anyone in your family have any diagnosis i should be aware of? * have you had any experiences or symptoms growing up that contributes to your health journey? * have you had any recent hospitalizations, injuries, or new symptoms? * current weight: * current height: * how many hours do you sleep a night (on average)? * less than 5 5-7 8-10 10+ what time do you wake up? // what time are you in bed? * rate your quality of sleep 1-10 * (1 = low, 10 = high) rate your daily energy 1-10 * (1 = low, 10 = high) how active are you? 1-10 * (1 = not at all, 10 = all day) how active is your job? 1-10 * (1 = sedentary, 10 = labor intensive) do you have any of the following? * check all that apply bloating constapation stomach pain gas burping diarrhea do you have any of the following? * check all that apply brain fog memory frustration/ forgetfullness known toxin exposure do you have any goals related to food and nutrition? * FOR EXAmPLE: weight loss/GAIN, COOK MORE, UNDERSTAND LABELS, ETC how would you describe your relationship with food? * do you have any food intolerances or allergies? * please specify. list 3 favorite foods * list 3 least favorite foods * do you... * check all that apply drink caffeine smoke/eat weed tabacco use drink alcohol Do you follow a specific eating approach/practice for personal, health, or religious reasons (vegan, ketogenic, kosher, ETC)? * what's your typical breakfast look like: * what's your typical lunch look like: * what's your typical dinner look like: * what's your typical snacks/dessert look like: * How would you describe your overall mental and emotional health? * How would you describe your overall mental and emotional health? * How do you like to support your mental health? what are your outlets? * do you have any rituals in form of meditation? journaling? grounding? * what is your occupation? * do you see yourself in this job long term? * what is your ideal career if money wasnt a factor? * how many hours per week do you work? * what hobbies/ activities do you enjoy doing? * is there anything you'd like to share about your social life? * is there anything you’d like to share about yourself we haven’t covered? * THANK YOU!
