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Health History Form
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Name:
Age:
Phone Number:
Email:
How would you rate your overall health?
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Do you have any chronic health conditions?
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Are you currently taking any medications? If so, please list them.
Do you have any allergies? If so, which ones?
Have you had any major surgeries or hospitalizations in the past year? If so, please explain.
How many days per week do you engage in physical exercise?
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What type of physical activities do you participate in? (Check all that apply)
On average, how long do you exercise during each session?
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Do you feel that you get enough physical activity?
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How many meals do you typically eat each day?
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Do you follow any specific diet or eating plan?
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How many servings of fruits and vegetables do you consume daily?
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How often do you consume sugary or processed foods?
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Do you drink alcohol, if so how many per week?
How much water do you drink daily?
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On average, how many hours of sleep do you get each night?
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Do you have trouble falling or staying asleep?
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Do you feel rested when you wake up in the morning?
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How would you rate your current stress level?
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Do you have strategies for managing stress?
How often do you feel overwhelmed or anxious?
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Do you have a support system in place (friends, family, support groups)?
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Do you smoke?
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How would you describe your work-life balance?
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Do you engage in any hobbies or activities that you enjoy?
What are your main health goals? (Check all that apply)
Are there any specific areas where you would like to make changes or improvements in your lifestyle?
Do you have any concerns or questions about your health or lifestyle that you would like to address?
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