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Health History Form
madnutrition
April 13, 2015
June 28, 2022
Health History Form
This is a form for new clients.
For existing clients, please fill out the
Client Re-Visit Form
.
Name
*
Date
Email
*
Times/day check email?
Rarely
1-2
3-4
5-6
7 or more
Home Phone
Work Phone
Cell Phone
Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Age
Height
Birth Date
Month
Day
Year
Place
Sex
Current Weight
Weight 6 months ago
1 Year Ago
What would you like your weight to be?
Choose one
Single
Married
Divorced
Children
Occupation
Hours/Week
Do you sleep well?
Yes
No
Do you wake up during the night?
Yes
No
What time?
To urinate?
Yes
No
What time do you generally get up in the morning?
Do you experience constipation/diarrhea?
Blood Type
Racial Ancestry?
Are your periods regular?
Yes
No
How many days is your flow?
How frequent?
Painful or symptomatic?
Do you take supplements or medications? If so, which?
Do you have food allergies? If so, list foods
Are there any healers, helpers or therapies with which you are involved? Please list:
What role does exercise play in your life?
Do you drink coffee, smoke cigarettes, or have any major addictions?
What percentage of your food is home cooked?
Where do you get the rest from?
Serious illness / hospitalizations / injuries:
Mother's Health?
Father's Health?
What is your chief concern?
Other concerns?
Breakfast
Lunch
Dinner
Snacks
Liquids
Breakfast
Lunch
Dinner
Snacks
Liquids
Breakfast
Lunch
Dinner
Snacks
Liquids
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