Confidential Health History

PERSONAL INFORMATION

Name:
Email:
Address:
City:
State: Zip/Postal Code:
Phone - Work: Phone - Home:
Phone - Cell:
Age: Height:
Date of Birth: Place of Birth:
Current Weight: Weight 6 Months Ago:
Weight 1 Year Ago:
Would you like your weight to be different? If so, what?
Relationship Status: Children?
Occupation: Hours of work per week:

HEALTH INFORMATION

Please list your main health concerns:
If you have had any recent and significant weight changes, why?
Any serious illness/hospitalizations/injuries?
Any pertinent medical history on your mother's side of the family?
Any pertinent medical history on your father's side of the family?
What is your ancestry? What blood type are you?
Do you sleep well? How many hours?
Do you wake up at night? If so, why?
Any pain, stiffness or swelling?
 
For Women Only:  
Are your periods regular? How many days is your flow? How frequent?
Painful or symptomatic? Please explain:
Birth control history:
Vaginal infections, reproductive concerns?
 
Do you have a history of Heart Burn/Reflux?
Do you feel bloated or uncomfortable after meals?
If yes, can you associate this feeling with any specific foods?
Constipation/Diarrhea/Gas? Please explain:
How often do you urinate in a day?
Do you ever have difficulty urinating?

MEDICAL INFORMATION

Do you take any supplements or medications? Please list:
Any healers, helpers, pets or therapies with which you are involved? Please list:
What role do sports and exercise play in your life?

FOOD INFORMATION

What Time to do get up in the morning?
What Time to you eat the following meals (a range is OK)?
  Breakfast Lunch
  Dinner Snacks
  Liquids
Is there a particular time of day you feel very hungry? If yes, when and why?
Is there a particular time of day you feel you eat/snack for reasons other than hunger? If yes, when and why?
What are some common food choices for the following meals?
  Breakfast Lunch
  Dinner Snacks
  Liquids
What percentage of your food is home cooked versus not home cooked?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?

ADDITIONAL INFORMTION

What are your biggest challenges when it comes to your overall health/wellness? (rate in order of importance with 1 being the most challenging and 8 being the least challenging): Diet (food choices)
Preparing on meals
Weight
Exercise
Stress
Sleep
Career
Relationships
What are your expectations associated with working with a dietitian or health coach?