Online Forms

Click on the links below, to download pdf’s of the forms.

Health History Form

First Name*


Last Name*


Email*


How often do you check e-mail:


Home Phone:


Work Phone:


Mobile Phone:


Age:


Height:


Birthdate:


Place of Birth:


Current weight:


Weight six months ago:


One year ago:


Would you like your weight to be different:


Social Information - Relationship status:


Where do you currently live?:


Children:


Pets:


Occupation:


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:


What is your ancestry:


What blood type are you:


How is your sleep:


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:


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: