move forward into better health. Fill out the health history form below for a free consultation Behavior Change is Difficult for all of us. I can help.Weight Loss and FitnessStress ManagementHealing Support Specialty (Dr.) Prescribed Diet Adherence Men’s Health Nutrition Coaching and Culinary GuidanceModerating or Quitting Unhelpful HabitsDivorce Support for Men Name First Name Last Name Age Sex Assigned at Birth Gender Identity Preferred Pronouns Occupation Email Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Communication Method Emergency Contact Name First Name Last Name Relationship Phone (###) ### #### What are your health goals and why are they important to you? What's the most important thing you'd like to share about your health story? Primary Care Physician (If you have one) Other Physicians or Specialists Practitioners, therapists, healers, etc. Please list any supplements or medications you take. Have you experienced any barriers or challenges to accessing healthcare? MEDICAL INFORMATION Please list any medical diagnoses or conditions: History of serious illnesses, hospitalizations, injuries, or surgeries: FAMILY HISTORY Describe the health of your Mother Describe the health of your Father Is there anything from your childhood pertaining to your health you'd like to share? Do you have any other notable family or personal health information you'd like to share? PHYSICAL HEALTH INFORMATION Current weight and height How many hours do you sleep per night on average? How would you describe your quality of sleep? On a scale of 1 to 5, 1 being "Very Low" and 5 being "Very High", how is your energy level most days? Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain: Do you have any of the following concerns ? (Check all that apply.) Metabolic health Blood Sugar Imbalances Elevated Blood Pressure Elevated Cholesterol Elevated Triglycerides Digestive Health Bloating Constipation Diarrhea Gas Nausea Stomach Pain How many bowel movements (on average) do you have per day? Reproductive Health Infertility Irregular Menstrual Cycle Low Libido Hormonal Health Thyroid Condition Toxin Exposure Signs or Symptoms of Hormonal Imbalance Immune Health Autoimmune Conditions Frequent Illness or Infection Low Vitamin D Level Allergies and Sensitivities Please list any allergies, sensitivities, and other immune health concerns. Brain Health Brain Fog Difficulty Concentrating Forgetfulness Enter any other brain health concerns NUTRITION INFORMATION What foods did you grow up eating? How would you describe your past relationship or history with food? Do any specific memories about food or eating come to mind? Describe your current relationship with food. Do you have any food allergies or intolerances? If so, please list: Do any of the following apply to you? (Check all that apply.) Challenges with Preparing Meals Challenges with Access to Food Difficulties Chewing or Swallowing Poor Appetite Do you regularly use any of the following? (Check all that apply.) Alcohol Tobacco Products Cannabis Other Substances Do you follow a specific eating approach/practice for personal, health, or religious reasons (e.g., vegan, ketogenic, kosher, halal)? If so, please explain: What does a typical day of eating look like for you? List a few foods/meals and drinks you usually consume in the corresponding categories: Breakfast Lunch Dinner Snacks What, if anything, would you like to change about your nutrition? MENTAL AND EMOTIONAL HEALTH INFORMATION How would you describe your overall mental and emotional health? How do you like to support your mental health? How do you cope with stress? Using a 1 - 5 scale (where 1 = never and 5 = always), rate how often you experience each of the following: Anger Excitement Fear Joy Love Sadness Stress Worry SPIRITUAL HEALTH INFORMATION What role does spirituality play in your life, if any? LIFESTYLE INFORMATION What are the important relationships in your life? Is there anything you'd like to share about your social life? If so, please explain: Who do you live with, if anyone? How many hours per week do you typically work? What hobbies or recreational activities do you enjoy? What role does movement, including sports, exercise, and physical activity, play in your life? ADDITIONAL COMMENTS Is there anything else you'd like to share? Thank you for submitting your health history. I will contact you to schedule your session. If you have any questions, you can text or call me at 530-566-4008.
