Health History
A New Path to Wellness Website Form
Email address *
Full Name *
Your answer
Age *
Your answer
Weight *
Your answer
Date of Birth *
Your answer
Place of Birth *
Your answer
How often do you check your email *
Home Phone *
Your answer
Mobile Phone *
Your answer
Current Weight *
Your answer
Weight Six Months Ago *
Your answer
Weight One Year Ago *
Your answer
Would you like your weight to be different? *
Your answer
If so, How?
Your answer
Social
Relationship Status *
Your answer
Where do you live? *
Your answer
Any children? *
Your answer
Any pets? *
Your answer
Occupation *
Your answer
How many hours do you work per week? *
Your answer
General Health
What are your main health concerns? *
Your answer
Any other concerns and/or goals? *
Your answer
At what point in your life did you fell your best? *
Your answer
Any current or previous serious illnesses, hospitalizations, or injuries? *
Your answer
How is/was your mother’s health? *
Your answer
How is/was your father’s health? *
Your answer
What is your ancestry? *
Your answer
What is your blood type? *
Your answer
How is your sleep? *
Your answer
How many hours do you sleep per night? *
Your answer
Do you wake up during the night? If so, why? *
Your answer
Any pain, stiffness, or swelling? *
Your answer
Any constipation, diarrhea, or gas? *
Your answer
Any allergies or sensitivities? *
Your answer
Medical
List all supplements or medications: *
Your answer
Are you involved with any healers, helpers, or therapies? *
Your answer
What role do sports and exercise play in your life? *
Your answer
Food
Will your family and friends be supportive of your desire to make food and/or lifestyle changes? *
Your answer
Do you cook? *
Your answer
What percentage of your food is home-cooked? *
Your answer
Where does your non-home-cooked food come from? *
Your answer
For Breakfast, which foods did you eat often as a child? *
Your answer
For Lunch, which foods did you eat often as a child? *
Your answer
For Dinner, which foods did you eat often as a child? *
Your answer
For snacks, which foods did you eat often as a child? *
Your answer
Which Liquids did you drink often as a child? *
Your answer
What foods do you typically eat these days?
For Breakfast, what do you typically eat these days? *
Your answer
For Lunch, what do you typically eat these days? *
Your answer
For Dinner, what do you typically eat these days? *
Your answer
For Snacks, what do you typically eat these days? *
Your answer
Which Liquids do you typically eat these days? *
Your answer
Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions? *
Your answer
What is the most important thing you should change about your diet to improve your health? *
Your answer
Additional Comments *
Your answer
Is there anything else you would like to share? *
Your answer
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