Health History Online Form

How did you find out about my webpage?*

Name*

First

Last

Email*

Phone (Home)*

Phone (Work)

Phone (Mobile)

Sex*

Male

Female

Age*

Height*

Date of Birth*

select a day

/

select a month

/

select a year

Place of Birth*

Current weight*

Weight six months ago*

Weight one year ago*

Would you like your weight to be different?*

Yes

No

What is your desired weight?*

1/6

Relationship status*

Where do you currently live?*

Do you have children?*

Yes

No

How many?*

Do you have pets?*

Yes

No

What are their names?*

Do you currently have an accupation?*

Yes

No

How many hours a week do you work?

2/6

Do you take any supplements or medications?*

Yes

No

Please list*

Any healers, helpers, or therapies with which you are involved?*

Yes

No

Please specify*

What role does sports and exercise play in your life?*

4/6

What foods did you eat often as a child?*

What is your food like these days?*

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

Yes

No

Do you cook?*

Yes

No

What percentage of your food is home-cooked?*

0

100

Where do you get the rest from?*

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

The most important thing I should change about my diet to improve my health is*

5/6

Anything else you would like to share?

6/6

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