Health History Intake FormPlease fill out the form below. Name * First Name Last Name Email * Phone * (###) ### #### Birthday * MM DD YYYY Current Weight * Goal Weight * Relationship Status * Single Married Separated Divorced Widowed Domestic Partnership Where do you currently live? * Children? * Occupation * Hours or work per week * Please list your main health concerns. * Other concerns/goals Any pain, stiffness, or swelling? Constipation/Diarrhea/Gas? Allergies or sensitivities? Please explain: Do you take any supplements or medications? Please list Any healers, helpers, or therapies with which you are involved? Please list: * What role does exercise play in your life? * What kinds of foods did you eat as a child? Please list a few examples from each meal. * What kinds of foods do you eat now? Please list a few from each meal. * Do you cook? What percentage of your food is home-cooked? * Do you crave sugar, coffee, cigarettes, or have any major addictions? * The most important thing I should do to improve my health is: * Anything else you would like to share? Thank you!
