Health History Survey

First Name

Last Name

Phone

Birthday

Age

What are your main health concerns?

Any other concerns or goals?

At what point in your life did you feel your best?

How is your sleep?

Any pain, stiffness or swelling

Any constipation, diarrhea or gas?

Any allergies or sensitivies

Are you involved with any healer, helpers or therapies?

What role does exercise and sports play in your life?

Will your family and friends be supportive of your desire to make food or lifestyle changes?

What percentage of your food is home-cooked? Where does your non-home-cooked food come from?

What foods do you typically eat? Breakfast, lunch, dinner, snacks, liquids

Do you crave sugar, coffee or cigarettes? Do you have any other major addictions?

What is your current weight?

What was your weight 6 months ago? One year ago? What do you think has contributed to any changes?

Would you like your weight to be different? If so, how and why?

What is the most important thing you should change about your diet to improve your health?

Is there anything else you would like to share?