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
Phone
Address
Street Address City State ZIP Code
Age
Birth Date
MM slash DD slash YYYY
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.
Occupation
Work Hours/Days
General Health Info
How would you rate your health?
Height Weight Desired 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 Habits
Do you skip meals?
If yes, what meals & why?
Do you crave certain foods?
What & when?
What do you feel are your worst eating habits?
What are your food dislikes?
Meal Planning
Who plans meals?
Who cooks?
Who shops?
How much do you eat out?
Food Preferences, Allergies and Intolerances
Do 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.
Do you drink alcohol? Describe the frequency, etc.
How do you cope with stress?
How many hours of sleep you get on average?
Exercise
What 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 ready
- 2. Moving forward at being ready
- 3. Somewhat ready
- 4. Almost ready
- 5. Very ready
On a scale of 1 (not confident) to 5 (very confident), how confident are you to make lifestyle changes?
- 1. Not confident
- 2. Moving forward at being confident
- 3. Somewhat confident
- 4. Almost confident
- 5. Very confident
List at least 3 specific goals or outcomes that you are hoping to get out of working together.

Height	Weight	Desired Weight

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!

Patient History

General Health Info

Medical History: Please complete the following.

Food Habits

Meal Planning

Food Preferences, Allergies and Intolerances

Exercise