Health Client Information Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Format: (000) 000-0000.
What is your age?
*
What is your TOP health Concern?
*
Tell me more about it: When was it diagnosed? Are you taking medications? Is it controlled? What are your goals in working with me?
*
What is your second most important Health Concern? (type NONE if there is none)
Tell me more about it: When was it diagnosed? Are you taking medications? Is it controlled? What are your goals in working with me?
What is your third most important Health Concern? (type NONE if there is none)
Tell me more about it: When was it diagnosed? Are you taking medications? Is it controlled? What are your goals in working with me?
Please mark the following if you have experienced any of the following in the last 12 months:
*
Acne
Allergies
Bloating
Cancer
Constipation
Diabetes
Diarrhea
Fatigue
Frequent Headaches
High Blood Pressure
High Cholesterol
Overweight / Obese
PeriMenopause / Menopause symptoms
PMS / Menstrual Irregularities
Stroke
Thyroid disease
Weight loss
Other
List all medications you have been prescribed. Also, Indicate whether or not you are currently taking them. If you have not been prescribed any, type NONE
*
List all supplements, herbs, vitamins you are taking. Also, Indicate why you are taking them. If you have not been taking any, type NONE
*
How often do you exercise? How long have you been doing this?
*
What type of exercise do you do?
*
What is a typical Breakfast for you?
*
What is a typical Lunch for you?
*
What is a typical Dinner for you?
*
What foods do you crave?
How many hours of sleep do you get each night? Do you feel rested?
*
How many cigarettes and / or cigars do you smoke each day or week?
*
Is there any other information that I should know before your appointment?
*
How willing are you to make changes to your diet?
*
Least Willing
1
2
3
4
5
6
7
8
9
Most Willing
10
1 is Least Willing, 10 is Most Willing
Will others in your household be willing to make diet and lifestyle changes with you?
*
Would you like to be on our newsletter list?
*
YES
No
How did you hear about us?
*
Submit
Should be Empty: