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