Initial Consultation - Health History
Rev. Dr. Yolanda Badillo, A.A.D.P., H.H.C., D.A. Hom., C.B.P.
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Client Name *
Street Adress *
City *
State *
Zip code *
Email address *
How often do you check your email? *
Home / cell phone *
Work phone
Age *
Date of Birth *
MM
/
DD
Place of Birth *
Your current weight *
Weight 6 months ago *
Weight 1 year ago *
Would you like your weight to be different? *
Required
If yes, then what is your ideal weight?
Occupation *
Relationship status *
If you have children, how many?
How many hours/week do you work? *
Do you sleep well? *
Required
Do you wake up at night? *
Required
If yes, what time/s do you wake up?
Do you wake in the night to urinate? *
Required
What time do you wake in the morning? *
Do you experience constipation or diarrhea? *
Required
If yes, please explain
What is your blood type? *
What is your ancestry? *
For women - Are your periods regular?
How many days is your flow?
How frequently do you get your period?
Are they painful or symptomatic?
If yes, please explain
Do you take any medications or health supplements?
If yes, please explain
Are there any other helpers, healers, pets, or therapies you are involved with?
If yes, please explain
What roll does exercise play in your life? *
Do you do any of the following?
Check all that apply
What percentage of your food is homemade? *
Where do you get the rest of your meals from? *
Please list your health history *
any illnesses / hospitalizations / injuries
Mother's health *
Father's health *
What is your main health concern? *
Any other concerns?
What foods did you eat most often for breakfast as a child? *
Lunch? *
Supper? *
Snacks? *
Liquids? *
What foods did you eat most often for breakfast one year ago? *
Lunch? *
Supper? *
Snacks? *
Liquids? *
What is your diet like now? *
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