Health History Form       Note : *-required fields       Client Name:*      Date:     Address:     City:     State:      Zip:     Email Address:*     How often do you check e-mail?   Telephone:* Work: Home:    Cell:       Age: Height:     Date of Birth: Place of Birth:           Current weight:       Weight six months ago?     One year ago?     Would you like your weight to be different? Yes    No If so, what?     Relationship status:  Children?     Occupation:     How many hours a week do you work?     Do you sleep well? Yes     No     Do you wake up at nights?   Yes    No What time(s)?     To urinate:      What time do you generally get up in the morning?     Do you experience constipation/diarrhea? Yes     No     If yes, please explain     What blood type are you?     What is your ancestry?     Women:   Are your periods regular?   Yes   No     How many days is your flow?     How frequent?     Painful or symptomatic? Yes   No     Please explain         Do you take any supplements or medications? If so, which?     Are there any healers, helpers or therapies with which you are involved? Please list:     What role does exercise play in your life?     Do you drink coffee, smoke cigarettes, or have any major addictions?     What percentage of your food is home cooked ? %     Where do you get the rest from?     Serious illness / hospitalizations / injury     How is the health of your mother?     How is the health of your father?     What is your chief concern?     Other concerns?           What foods did you eat often as a child? Breakfast   Lunch   Dinner   Snacks   Liquids   What about one year ago? Breakfast   Lunch   Dinner   Snacks   Liquids     What's your food like these days? Breakfast   Lunch   Dinner   Snacks   Liquids
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