Health History
All members of Honeybee Wellness are invited to complete the Health History Questionnaire. Some of these questions may not seem relevant to your concerns, but it's helpful for me to know these things so that I can get the "big picture" of your life. YOUR RESPONSES ARE KEPT CONFIDENTIAL. If you have any questions, feel free to email me at melissa@honeybeeholistic.info
Email address
Your Name
Your answer
Best Number to Reach You At
Your answer
Best Email to Reach You At
Your answer
City/State
Your answer
How old are you?
You can give a range, i.e., 30ish
Your answer
Where were you born/raised? Where do you live now?
Your answer
Describe your ancestry
Your answer
How many hours of sleep do you get a night? Do you sleep through the night? Do you wake up (for no reason, to urinate, etc)? Do you take naps during the day?
Your answer
Are you in a relationship? If yes, how's it going? If no, would you like to be?
Your answer
Do you have any children? If yes, what ages?
Your answer
Are you working, in school? Full-time, part-time? Unemployed? Describe your current situation and how you'd like it to improve, or if you're satisfied
Your answer
What is your main health concern?
Your answer
How's your libido? Do you find it easy to get in the mood or do you have to mentally and physically prepare for sexual activity? Are you experiencing trouble lubricating naturally or maintaining an erection?
You are considered sexually active even if you're not having sex by choice, if you masturbate, have vaginal or anal intercourse, and/or engage in oral sex.
Your answer
WOMEN: Are you menstruating or menopausal? Describe your menstrual cycle - What kind of PMS symptoms do you experience, how heavy is your flow, how many days does it last, describe your energy levels, cravings, discomfort, etc
Your answer
List your top three health and wellness goals
Your answer
At what point in your life did you feel at your best? What changed?
Your answer
What kind of physical activities do you like to engage in?
Your answer
Describe your eating habits. Are you looking to change them? Transition to something else?
Your answer
How many of your daily meals do you prepare at home? How often do you eat out?
Your answer
Do you consume alcoholic beverages?
No judgments here
How about recreational drugs?
Again, no judgments here
List any cravings/addictions - coffee, sugar, cigarettes, etc
Again, no judgments here
Your answer
Describe your poop behavior/schedule. Seriously.
How many times a day/week? Any constipation, diarrhea, gas, bloating? Straining or easy poops? Big, soft, and well-formed or small and hard?
Your answer
Are you happy with your weight? If not, what would you like to change about it?
Your answer
What is the ONE thing you'd REALLY like to try but have always been afraid to do by yourself?
Your answer
Do you have any health issues or physical conditions I should know about?
This includes food allergies/sensitivities, conditions that require medication, dietary observances/restrictions, old surgeries/injuries - especially joint/spine stuff
Your answer
What is your family's health like? Is there a history of illness, disease, etc?
Conditions like diabetes, high blood pressure, cancer, autoimmune disorders, blood disorders, mental health disorders, etc
Your answer
Do you participate/practice in any therapeutic, spiritual and//or alternative health therapies/modalities? If yes, please describe
Yoga, meditation, massage therapy and other bodywork, acupuncture, martial arts, art therapy, psychotherapy, etc
Your answer
Is there anything else you'd like me to know about you?
Your answer
How did you hear about me?
Your answer
A copy of your responses will be emailed to the address you provided.
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