Health History | Nourished Living

Please take 15 minutes to really think about your answers. Be honest and thorough. The more information I have before we meet, the more we’ll be able to accomplish during our time together. Your responses will be kept confidential.

Personal Information

Name *

First

Last *

Last

Email *

Phone Number *

Website

Address *

Address Line 2

City *

State *

Postal Code

Country *

How did you hear about me?

Internet

Facebook

Friend/Family

Other

Friend/Family

Other

Age

Height

Date of birth

Why?

Current weight

Weight Six Months Ago

One year ago

Would you like your weight to be different?

Yes

If so, what?

Relationship status

Number of children

Number of pets

Lifestyle

What are you current primary sources of stress?

How much do you think they impact your health / life?

Occupation?

Do you like your work?

How many hours do you work per week?

Number of play/relaxation hours per week?

What do you do in order to manage stress and take care of yourself?

What is your exercise routine?

What time do you generally fall asleep at night?

What time do you get up in the morning?

Do you sleep well?

Yes

Sometimes

Do you wake up at night?

Yes

What times?

Time

Why do you wake up at night?

Food Information

Breakfast

Lunch

Dinner

Snacks

Beverages

What foods do you crave or feel addicted to?

What time of day do your cravings hit the hardest?

List any foods your body reacts negatively to along with a description of the reactions

What percentage of your food is home cooked?

Where do you get the rest from?

How do you feel about cooking?

Sources and amounts of Caffeine:

Sources and amounts of Alcohol:

Smoking history:

Health Information

Please check and describe any problems in any of these areas. Please don’t limit your responses to this list. Write in any other problems / health challenges you’re currently experiencing or are concerned may be headed your way if you don’t make food and lifestyle changes now.

Energy Level

Mood (e.g. anxiety, depression

Headaches

Nose/sinuses (allergies, sinus infection, congestion)

Digestive concerns (constipation, diarrhea, heartburn, bloating, hemorrhoids)

Body aches and pains (arthritis, joint pain)

Skin (psoriasis, eczema, rashes)

Food allergies / sensitivites

Other:

Women

Are your periods regular?

Yes

How many days is your flow?

How frequent?

Painful or symptomatic?

Yes

Please explain

Reaching or approaching menopause?

Yes

Symptoms?

Yes

Please Explain

Do you experience yeast or urinary tract infections?

Birth control history:

Additional information

The most important thing you could do to improve your health?

Is there anything else at all you’d like to share with me?

Thank you for taking the time to complete this form. I look forward to meeting with you!

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