Client Confidential Health History

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 *

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) *

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)? *

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)? *

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? *

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.

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.

Comment or details on sinus problems. *