Health History Form
Phone - work
Date of Birth
Place of Birth
Weight six months ago?
One year ago?
Would you like your weight to be different?
If so, what?
How many hours a week do you work?
Do you sleep well?
Do you wake up at night?
What time do you generally get up in the morning?
Are your periods regular?
How many days is your flow?
Painful or symptomatic?
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?
What is your chief health concern?
What foods did you eat often as a child?
What about a year ago?
What's your food like these days?