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Confidential Health History Form
Name *
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Address
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Email *
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Phone *
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Age
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Date of Birth
MM
/
DD
/
YYYY
Height
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Current Weight
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Please list your main health concerns
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Any serious illnesses/hospitalization/injuries?
Your answer
How is/was the health of your mother?
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How is/was the health of your father?
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Do you sleep well?
How many hours a night?
Your answer
Any pain or stiffness or swelling?
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Any other health concerns, constipation/diarrhea/gas/allergies or sensitivities? Please explain:
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Do you take and medications or supplements? Please list:
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What role does exercise play in your life?
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List any regular exercise:
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How is your energy level?
Low
High
What foods do you eat regularly?
Breakfast?
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Lunch?
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Dinner?
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Snacks?
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Liquids?
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What percentage of your food is home cooked?
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Where does the rest come from?
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Do you have cravings for sugar, chocolate, coffee, any major addictions?
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The most important thing I should change about my diet to improve my health is:
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Anything else you want to share?
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