Health History Form Client Name   Address         City               State    Zip Phone - work    home    Email Age    Date of Birth    Place of Birth Current weight    Weight six months ago?    One year ago? Would you like your weight to be different? Yes No   If so, what? Relationship status    Children?    Occupation    Blood Type How many hours a week do you work? Do you sleep well? Yes No    Do you wake up at night? Yes No    What time(s)? What time do you generally get up in the morning?    Constipation/Diarrhea Women: Are your periods regular? Yes No     How many days is your flow?    How frequent? Painful or symptomatic? Yes No     Please explain 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? How is the health of your father? How is the health of your mother? Serious illness/hospitalization/injury What is your chief health concern? Other concerns? What foods did you eat often as a child? breakfast   lunch   dinner   snacks   liquids What about a year ago? breakfast   lunch   dinner   snacks   liquids What's your food like these days? breakfast   lunch   dinner   snacks   liquids