Female Health FormMale Health FormWomen’s Health HistoryAll of your information will remain confidential. Date of Birth: Would you like your weight to be different?: If so, what?: Social Information Relationship status: Where do you currently live?: Children: pets: Ocupation: Hours of work per week: Health Information Please list your main health concerns: Other concerns and/or goals?: At what point in your life did you feel best?: Any serious illnesses/hospitalizations/injuries?: How is/was the health of your mother?: How is/was the health of your father?: What is your ancestry?: What blood type are you?: How is your sleep?: Any serious illnesses/hospitalizations/injuries?: How many hours?: Do you wake up at night?: why?: Any pain, stiffness or swelling?: Constipation/Diarrhea/Gas?: Allergies or sensitivities? Please explain: Are your periods regular?: How many days is your flow?: How frequent?: Painful or symptomatic? Please explain: Reached or approaching menopause? Please explain: Birth control history: Do you experience yeast infections or urinary tract infections? Please explain: Medical Information Do you take any supplements or medications? Please list: Any healers, helpers or therapies with which you are involved? Please list: What role do sports and exercise play in your life?: Food Information What foods did you eat often as a child? Breakfast: Lunch: Dinner: Snacks: Liquids: Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?: Do you cook?: What percentage of your food is home-cooked?: Where do you get the rest from?: Do you crave sugar, coffee, cigarettes, or have any major addictions?: The most important thing I should do to improve my health is: What is your food like these days? Breakfast: Lunch: Dinner: Snacks: Liquids: Additional Comments Anything else you would like to share?: Men’s Health HistoryAll of your information will remain confidential. Date of Birth: Would you like your weight to be different?: If so, what?: Social Information Relationship status: Where do you currently live?: Children: pets: Ocupation: Hours of work per week: Health Information Please list your main health concerns: Other concerns and/or goals?: At what point in your life did you feel best?: Any serious illnesses/hospitalizations/injuries?: How is/was the health of your mother?: How is/was the health of your father?: What is your ancestry?: What blood type are you?: How is your sleep?: Any serious illnesses/hospitalizations/injuries?: How many hours?: Do you wake up at night?: why?: Any pain, stiffness or swelling?: Constipation/Diarrhea/Gas?: Allergies or sensitivities? Please explain: Medical Information Do you take any supplements or medications? Please list: Any healers, helpers or therapies with which you are involved? Please list: What role do sports and exercise play in your life?: Food Information What foods did you eat often as a child? Breakfast: Lunch: Dinner: Snacks: Liquids: Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?: Do you cook?: What percentage of your food is home-cooked?: Where do you get the rest from?: Do you crave sugar, coffee, cigarettes, or have any major addictions?: The most important thing I should do to improve my health is: What is your food like these days? Breakfast: Lunch: Dinner: Snacks: Liquids: Additional Comments Anything else you would like to share?: