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Home
About Me
Integrative Nutrition Health Coach
Work with Me
Health Coach Services
My Approach
Forms
>
Revisit Form
Confidential Health History Form
Contact
Blog
Recipes
Health History - Men
PERSONAL INFORMATION
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Indicates required field
Name
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First
Last
Email
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How often do you check email?
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Cell Phone Number
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Work Phone Number
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Home Phone Number
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Age
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Height
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Birthdate
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Place of Birth
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Current Weight
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Weight 6 months ago
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1 year ago
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Would you like your weight to be different? and if so, what?
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SOCIAL INFORMATION
Relationship status:
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Where do you currently live?
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Children
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Pets
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Occupation
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Hours per week
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HEALTH INFORMATION
Please list your main health concerns
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Other concerns and/or goals?
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At what point in your life did you feel best?
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Any serious illnesses/hospitalizations/injuries?
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How is the health of your mother?
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How is the health of your father?
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What is your ancestry?
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What blood type are you?
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How is your sleep?
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How many hours?
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Do you wake up at night?
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Often
Sometimes
Rarely
Never
If you wake at night, why?
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What do you think is the reason for your sleeping problems (if any)?
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Any ongoing sources of inflammation (e.g. eczema or other skin irritation, chronic post nasal drip, congestion, headaches, achy muscles/joints, swelling, pain, stiffness)?
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Do you struggle with any of the following?
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Constipation
Diarrhea
Gas
Distension
Belching
Bloating
Please explain your answer to the previous question in detail.
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How often do you have bowel movements?
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MEDICAL INFORMATION
Please list ALL supplements or medications you take (prescription or over the counter) and frequency.
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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?
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Any healers, helpers or therapies with which you are involved? Please list:
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What is the general status of your dental/health care?
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Any troubling dental work or history of dental/oral infections? Dentures? Root canals?
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How many silver/mercury fillings do you have?
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Have you had any other major dental work/issues beyond basic cleanings?
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Any remarkable exposure to toxins (e.g. current or childhood home, nearby industrial community, job, hobbies, travel, pesticides, heavy metals)?
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What roles do sports and exercise play in your life?
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What do you do to relax? How often?
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On a scale of 1 to 10, how would you rate your general energy level (1=lowest)?
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1
2
3
4
5
6
7
8
9
10
To what do you attribute this energy level?
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What was your general health and well-being as a child?
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FOOD INFORMATION
What foods did you eat often as a child?
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What is your food like these days?
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Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
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Yes
No
Do you cook? and What percentage of your food is home-cooked?
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Where do you get the rest of your food from that isn't home-cooked?
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Do you crave sugar, carbs, alcohol, coffee, other foods, cigarettes or have any major addictions?
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Do you have any food allergies or sensitivities?
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If you have a general philosophy, mindset or approach you use when choosing foods, please describe it briefly.
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The most important thing I should do to improve my health is:
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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.
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Headache
Faintness
Dizziness
Insomnia
Stuffy Nose
Sinus Issues
Hay Fever
Comment or details on head symptoms:
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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
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0
1
2
3
4
Comments or details on headaches.
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Faintness
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0
1
2
3
4
Comments or details on faintness.
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Dizziness
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0
1
2
3
4
Comments or details on dizziness.
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Insomnia
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0
1
2
3
4
Comments or details on insomnia.
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Stuffy Nose
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0
1
2
3
4
Comments or details on stuffy nose.
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Sinus Problems
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0
1
2
3
4
Comment or details on sinus problems.
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Hay Fever
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0
1
2
3
4
Comment or details on hay fever.
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Additional Comments
*
Submit