Health History Form Health History FormPERSONAL INFORMATIONFull Name:Date of Birth:Age:Sex Assigned at Birth:Gender Identity:Preferred Pronouns:Occupation:Email:Phone:Home Address:Preferred Contact Method: Phone Text Email MailEmergency Contact Name:Relationship:Phone:HEALTH AND WELLNESS GOALS What are your health and wellness goals? Why are they important to you?PERSONAL HEALTH AND FAMILY HISTORY Health InformationWhat’s the most important thing you’d like to share about your health story?Do you have any of the following? If so, please list: Do you have any of the following? If so, please list: Other physicians or specialists:Practitioners, therapists, healers, etc.:Please list any supplements or medications you take: Have you experienced any barriers or challenges to accessing healthcare?Medical InformationDo you have any of the following? If so, please list.Medical diagnoses or conditions: History of serious illnesses, hospitalizations, injuries, or surgeries:Family HistoryDescribe the health of your:Mother:Father: Is there anything from your childhood pertaining to your health you’d like to share?Do you have any other notable family or personal health information you’d like to share?NUTRITION INFORMATIONCurrent Weight:Height:Sleep:How many hours do you sleep per night on average?How would you describe your quality of sleep?How is your energy level most days? 1 2 3 4 5Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain:Do you have any of the following concerns? (Check all that apply.)Metabolic health Blood Sugar Imbalances Elevated Blood Pressure Elevated Cholesterol Elevated Triglycerides Other:Digestive health Bloating Constipation Diarrhea Nausea Stomach Pain Other:How many bowel movements (on average) do you have per day?Reproductive health Infertility Irregular Menstrual Cycle Low Libido Other:Hormonal health Thyroid Condition Toxin Exposure Signs or Symptoms of Hormonal Imbalance (please list)Immune health Autoimmune Conditions Low Vitamin D Level Frequent Illness or Infection Allergies and Sensitivities (please list) Other:Brain health Brain Fog Difficulty Concentrating Forgetfulness Other:NUTRITION INFORMATIONWhat foods did you grow up eating?How would you describe your past relationship or history with food? Do any specific memories about food or eating come to mind?Describe your current relationship with food. Do you have any food allergies or intolerances? If so, please list: Do any of the following apply to you? (Check all that apply.) Challenges with Preparing Meals Difficulties Chewing or Swallowing Poor Appetite Challenges with Access to FoodDo you regularly use any of the following? (Check all that apply.) Alcohol Tobacco Products Other Substances:Do you follow a specific eating approach/practice for personal, health, or religious reasons (e.g., vegan, ketogenic, kosher)? If so, please explain:What does a typical day of eating look like for you? List a few foods/meals and drinks you usually consume in the corresponding categories:BreakfastLunchDinnerSnacksDo you follow a specific eating approach/practice for personal, health, or religious reasons (e.g., vegan, ketogenic, kosher)? If so, please explain:MENTAL AND EMOTIONAL HEALTH INFORMATION How would you describe your overall mental and emotional health?How do you like to support your mental health?How do you cope with stress?Using a 1–5 scale (where 1 = never and 5 = always), rate how often you experience each of the following: Anger Excitement Fear Joy Love Sadness Stress WorrySPIRITUAL HEALTH INFORMATIONWhat role does spirituality play in your life, if any?LIFESTYLE INFORMATIONWhat are the important relationships in your life?Is there anything you’d like to share about your social life? If so, please explain:Who do you live with, if anyone?How many hours per week do you typically work?What hobbies or recreational activities do you enjoy?What role does movement, including sports, exercise, and physical activity, play in your life?ADDITIONAL COMMENTSIs there anything else you’d like to share?Submit Form
