Health Forms

If you are interested in becoming a client please fill out one of these health history forms. You may either download & return this form by clicking here. If you would like to save your progress you must download the form above, if you are ready to enter all of your health history now then you may also fill out the form below.
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Health History Form
Nameyour full name
Date
Street Address
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How often do you check email?
Phone (Work)
Phone (Home)
Phone (Mobile)
Age
Height
Date of birth:
Place of birth:
Current weight:
Weight six months ago:
One year ago:
Would you like your weight to be different?
If so, what?
If you have extra weight, where do you carry it?
Relationship status, name and age if applicable:
Relationship satisfaction rating (10 high – 1 low):
Children, names and ages if applicable:
Child related stress level rating (10 high – 1 low):
Pets, type and names if applicable:
Occupation:
Company:
Hours of work per week:
Job satisfaction rating (10 high – 1 low):
Job stress level rating (10 high – 1 low):
Other activities outside of work and relationship:
Have you experienced depression or anxiety, indicate length of time:
What is your attitude toward life? (10 optimistic/positive – 1 pessimistic/negative):
Do you feel/get angry? (10 rarely – 1 often)
Do you sleep well?
What time do you go to bed?
Do you wake up at night?
If so, what times?
Do you know why you wake up?
What time do you wake up in the morning?
Do you snore?
Do you grind your teeth?
Do you sleep in a dark room?
Do you have digestive problems? Constipation/Diarrhea?
How often do you have bowel movements?
Describe the texture/shape of your bowel movements?
Have you ever had delayed food allergy testing?
Do you have any joint pain or stiffness?
If so, describe:
What is your energy level (10 high – 1 low)?
Describe the texture/color of your nails:
Do you know your blood type? If so, what type are you?
What is your ethnic ancestry?
What are your cholesterol levels? If so, what are they?
Do you know your average blood pressure? If so, what is it?
Basal body temperatur:Temperature, using glass thermometer, before getting out of bed in the morning…leave thermometer under tongue for 10 minutes.
Do you know your average ph level? If so, are you acidic or alkaline and at what number?(check PH of urine or saliva upon waking and 2 hours after meals and record)
How much water do you drink per day?
So you know if your water is acid or alkaline and what the Ph of the water is…and if it’s negatively or positively charged?
Women:
Are your periods regular?
How many days is your flow?
How many days is your full cycle?
Are your periods symptomatic or painful? If so, how?
Are you taking any hormones?
Have you started menopause?
Men or Women
Have you had your hormone levels tested (ie testosterone, estrogen, progesterone, DHEA, Cortisol, etc?) If so which ones, and what were the results?:
Do you take supplements and are they a drug or bio identical?
Are you on any medications?
Do you see any MDs, Dentists or other medical professionals? If so, who and for what?
How often do you have medical checkups?
How often do you see the dentist?
Do you have silver (mercury amalgam) fillings?
Do you use floss or toothpicks?
Do your gums bleed when you brush or floss?
Are you working with any other healers, helpers or therapists? If so, who and for what?
Exercise
What role does exercise play in your life?
How many times per week and for how long?
Do you sweat when you exercise?
Do you do weight bearing exercise activities?
Do you stretch?
Do you relax, how often and for how long?
Do you use a sauna or hot tub?If so, what type of water is used?
Do you swim in chlorinated water?
At rest, how would you describe your breathing (shallow, deep, rapid, etc):
Do you mediate?
If so, how often and for how long?
Do you have a shower filter?
Do you know about the benefits of Far Infrared Sauna? Do you use one? If so, how often?more details
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Are you exposed to electromagnetic fields from computer, electric wires, mobile phone, etc? If so, do you use anything to filter exposure or neutralize it?
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Do you use an organic dry cleaner?
Do you use regular personal care products or natural/organic ones?
Do you use regular cleaning products or natural/organic ones?
How much natural sunlight do you get on an average day?
What type of lighting are you exposed to most of the time (fluorescent, regular, full spectrum bulbs)?more details
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Have you ever taken antibiotics?If so, how often?
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Have you ever been tested for Candida overgrowth?
Do you listen to loud music?
How much TV to you watch?
Do you watch/read listen to news?
Do you watch violent programs/movies?
How much driving do you do? Rate stress level while in car (10 high – 1 low):
How many hugs to you give and get per day?
How often do you laugh (10 a lot – 1 infrequently):
Do you get massages?If so, how often?
What type of bed to you sleep on?
How often do you change your bed sheets?
Do you drink coffee, smoke cigarettes or have any other addictions?
Are you exposed to second-hand smoke?
Do you have caffeine?
If so, in what form?
What % of your food is home cooked?
Where do you get the rest of your food?
Do you read food labels?
If yes, what do you look for or avoid?
Have you had any serious injuries, hospitalizations or illnesses?
What are three goals for your health?
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Describe the health of your mother (if deceased, at what age did she die?):
Describe the health of your father (if deceased, at what age did he die?):
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Do you cook in a microwave?
What type of cookware do you use (aluminum, Teflon, glass, stainless steel, etc.)?
Do you use plastic wrap on dishes?
Do you wash your fruits and vegetables before you eat them?
How much of your food is organic/free range without antibiotics or hormones?
Do you consume aspartame, Sweet N Low, Splenda, Equal, or other artificial sweeteners?
Most diseases are inflammatory; do you know what foods/supplements are anti-inflammatory in nature?If so, please list some of the main ones you are aware of, and also which foods CAUSE inflammation:
How many times do you chew your food before you swallow?
How much salt do you use and what kind?(ie iodized table salt, sea salt, etc)
When you eat, do you eat a little of everything or one type of food on the plate first, describe?
Foods you ate as a child / time of meals
Breakfast
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Lunch
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Snacks
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Liquids
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Dinner
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Foods you ate as a young adult
Breakfast
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Lunch
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Dinner
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Snacks
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Liquids
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Foods you eat now, if different
Breakfast
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Lunch
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Dinner
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Snacks
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Liquids
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