Brand New Day Wellness
Home
About Me
Integrative Nutrition Health Coach
Work with Me
Health Coach Services
My Approach
Forms
Contact
Blog
Health
Recipes
Home
About Me
Integrative Nutrition Health Coach
Work with Me
Health Coach Services
My Approach
Forms
Contact
Blog
Health
Recipes
Client Confidential Health History
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
How often do you check your email?
*
Daily
Weekly
Monthly
Home Phone Number
*
Cell Phone Number
*
Work Phone
*
Age
*
Height
*
Birthdate
*
Current Weight
*
Weight 6 months ago
*
1 year ago
*
Would you like your weight to be different? and if so, what would you like it to be??
*
What is your gender?
*
Male
Female
Occupation
*
Hours per week
*
Relationship status:
*
What is your ancestry?
*
Where do you currently live?
*
Major Health Concerns?
*
When was the last time you felt really Vibrant and well?
*
Other currant major life concerns?
*
If you could wave a magic wand and change two things what would they be?
*
Please list your main health concerns
*
Other concerns and/or goals?
*
Any serious illness, hospitalization, injuries and surgeries either now or in your past?
*
How is the health of your mother? (If deceased relay illness)
*
How is the health of your father? (If deceased relay illness)
*
What is your ancestry?
*
What is your blood type?
*
Do you sleep well?
*
Yes
No
Other
How many hours?
*
Do you wake up at night?
*
Often
Sometimes
Rarely
Never
What do you think is the reason for your sleeping problems (if any)?
*
Any ongoing sources of inflammation (e.g. eczema or other skin irritation, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)?
*
Do you struggle with any of the following?
*
Constipation
Diarrhea
Gas
Distension
Belching
Bloating
Please explain your answer to the previous question in detail.
*
How often do you have bowel movements?
*
Please list ALL supplements or medications you take (prescription or over the counter) and frequency.
*
Have you ever taken antibiotics more than a short course or two as a child? If so, when/how often? For what? And for how long?
*
What is the general status of your dental/health care?
*
Any troubling dental work or history of dental/oral infections? Dentures? Root canals?
*
How many silver/mercury fillings do you have?
*
Have you had any other major dental work/issues beyond basic cleanings?
*
Any remarkable exposure to toxins (e.g. current or childhood home, nearby industrial community, job, hobbies, travel, pesticides, heavy metals)?
*
What roles do sports and exercise play in your life?
*
What do you do to relax? How often?
*
On a scale of 1 to 10, how would you rate your general energy level (1=lowest)?
*
1
2
3
4
5
6
7
8
9
10
To what do you attribute this energy level?
*
What was your general health and well-being as a child?
*
Any healers, helpers, pets or therapies with which you are involved? Please list:
*
What are your primary hobbies?
*
FOOD INFORMATION
What foods did you eat often as a child?
*
What is your food like these days?
*
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
*
Yes
No
Do you cook? and What percentage of your food is home-cooked?
*
Where do you get the rest of your food from that isn't home-cooked?
*
Do you crave sugar, carbs, alcohol, coffee, other foods, cigarettes or have any major addictions?
*
Do you have any food allergies or sensitivities?
*
If you have a general philosophy, mindset or approach you use when choosing foods, please describe it briefly.
*
The most important thing I should do to improve my health is:
*
RATE THE SEVERITY OF EACH SYMPTOM YOU HAVE EXPERIENCED OVER THE PAST TWO YEARS.
Check any head symptoms you have experienced in the past two years.
*
Headache
Faintness
Dizziness
Insomnia
Stuffy Nose
Sinus Issues
Hay Fever
Comment or details on head symptoms:
*
Symptom Questionnaire
Use a 0 if you never have the symptom.
Use a 1 if you occasionally have it and the effect is mild.
Use a 2 if you occasionally have it and the effect is severe.
Use a 3 if you frequently or consistently have it and the effect is mild
Use a 4 if you frequently or consistently have it and the effect is severe.
Headache
*
0
1
2
3
4
Comments or details on headaches.
*
Faintness
*
0
1
2
3
4
Comments or details on faintness.
*
Dizziness
*
0
1
2
3
4
Comments or details on dizziness.
*
Insomnia
*
0
1
2
3
4
Comments or details on insomnia.
*
Stuffy Nose
*
0
1
2
3
4
Comments or details on stuffy nose.
*
Sinus Problems
*
0
1
2
3
4
Comment or details on sinus problems.
*
Hay Fever
*
0
1
2
3
4
Comment or details on hay fever.
*
Additional Comments
*
Submit