New Client Forms Page Title: Health History Form YOUR HEALTH HISTORY Form Yeah! I am so excited that you are moving forward and on your way to an abundant life! Please fill up the form below so I can learn more about your Health History and prepare for our work together. Talk soon, Colleen Patient History Name First Last Email PhoneAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code AgeBirth Date What time and where were you born?I read birth charts ( astrology) if you would like some insight on different parts of your health, please list these details so I can do this for you. OccupationWork Hours/DaysGeneral Health InfoHow would you rate your health?PoorFairGoodExcellentHeightWeightDesired Weight What is your lowest adult weight? At what age?What is your highest adult weight? At what age?Do you have a history of dieting? If yes, please list when you started and reasons for diet.Medical History: Please complete the following.Please check the items below that apply. (Yes) Heart Disease Stroke High Blood Pressure Chest Pain Shortness of Breath Irregular Heartbeat High Cholesterol Swelling of Feet/Hands Gallbladder Disease Diabetes Kidney Disease Seasonal Allergies Arthritis Osteoporosis/ Osteoarthritis Ulcers Constipation Chronic Diarrhea Irritable Bowel Colitis Crohn’s Disease Low Back Pain Gout Chronic Cough Asthma Attention Deficit Disorder Reflux/Heartburn Lactose Intolerance Dizziness Fainting Anxiety Depression Disordered Eating Suicide Attempt Thyroid Disease Liver Disease Lung Disease Cancer Anemia Sinusitis/Rhinitis Frequent Headaches Eczema Skin Disorders Celiac Disease Fibromyalgia Chronic Fatigue Syndrome Self-Mutilation Alcohol Abuse Drug Use Tobacco Use Nausea/ Vomiting OTHER Illnesses Please explain any 'Yes' answers.Are you presently taking any medications? If yes, please list the name and the dose.Are you presently taking any dietary supplements? If yes, please list the type, brand name and dose.Food HabitsDo you skip meals?YesNoIf yes, what meals & why?Do you crave certain foods?YesNoWhat & when?What do you feel are your worst eating habits?What are your food dislikes?Meal PlanningWho plans meals?Who cooks?Who shops?How much do you eat out?Food Preferences, Allergies and IntolerancesDo you have any dietary preferences that may limit your food choices? (Example: No red meat)Do you have any medical restrictions and must limit certain foods? (Example: High blood pressure- No salt)Do you have any food allergies, either diagnosed or suspected? (Example: Ended up in the ER after eating crab)Do you have any food aversions? (Example: I will not eat cooked vegetables)Do you have any food intolerances that give you indigestion? (Example: Milk gives me gas and diarrhea)Lifestyle: Choose the best that describes your energy level.Usually energetic/occasionally tiredAverage energy– sometimes more energetic/sometimes more tiredFrequently tired/occasionally energeticAlways tired/no energyDo you drink alcohol? Describe the frequency, etc.How do you cope with stress?How many hours of sleep you get on average?ExerciseWhat is the most physically active thing you do in an average day?What, if any, regular exercise do you do? How often and how long do you participate?On a scale of 1 (not ready) to 5 (very ready), how ready are you to make lifestyle, including dietary changes?1. Not ready2. Moving forward at being ready3. Somewhat ready4. Almost ready5. Very readyOn a scale of 1 (not confident) to 5 (very confident), how confident are you to make lifestyle changes?1. Not confident2. Moving forward at being confident3. Somewhat confident4. Almost confident5. Very confidentList at least 3 specific goals or outcomes that you are hoping to get out of working together. This iframe contains the logic required to handle AJAX powered Gravity Forms.