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Health History Questionnaire
All questions contained in this questionnaire are strictly confidential.
Please share whatever information you feel comfortable sharing.
The more I know about you the, the better able I can evaluate your concerns and goals.

* Required fields
Name *
E-mail Address *
How often do you check your e-mail?
Address
City
State
Zipcode
Phone (Work)
Phone (Home)
Phone (Cell)
	Male Female
Birthday (ex: January 1, 1965)
Relationship Status
Children's Names and Ages if Applicable
Occupation
How many hours per week do you work?
Current Weight
Weight 6 Months Ago
Weight 1 Year Ago
Would you like your weight to be different?	Yes No
If so, what?
Are you currently dieting?	Yes No
If so, what diet are you using?
Have you tried any diets in the past?	Yes No
If so, which one(s)?
List any medical problems any doctors have diagnosed?
Surgeries or Hospitalizations
Are you currently taking any prescribed medication, over-the-counter medicines, vitamins, supplements, etc.?	Yes No
Please List Prescribed Medications:
Please List Over-The-Counter Drugs:
Please List Vitamins, Supplements, Other:
Father	Living Deceased
Age
Significant Health Problems
Mother	Living Deceased
Age
Significant Health Problems
Siblings with Significant Health Problems (Living or Deceased)
Paternal Grandparents with Significant Health Problems (Living or Deceased)
Maternal Grandparents with Significant Health Problems (Living or Deceased)
Does anything on the list below apply to you? If so, check which ones:	Yes No
	Stress is a challenge for me
	I would like to have more energy
	I am often overwhelmed
	I don't sleep well
	I find being organized difficult
	Preparing Meals is a challenge
	Meal planning is a challenge
	Food shopping is a challenge
	Exercise is a challenge
WOMEN ONLY - (Men please scroll down to MEN ONLY)
I still have a period	Yes No
My period is:
	Heavy
	Irregular
	Spotting
	Painful
I am:	Pregnant Breastfeeding
I have had a D & C or hysterectomy:	Yes No
Any urinary tract, bladder, or kidney infections within the last year?	Yes No
Do you get up to urinate during the night?	More than once a night Once a night Occassionally Never
Any hot flashes or sweating at night?	Yes No
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around the time of your period?	Yes No
How frequently do you have a bowel movement?	More than once a day Once a day Every other day Less than 3 times a week
Do you have diarrhea?	Daily At least once a week Occasionally Never
MEN ONLY -
Do you get up to urinate during the night?	More than once a night Once a night Occassionally Never
Have you had any kidney, bladder, or prostrate infections within the last 12 months?	Yes No
How frequently do you have a bowel movement?	More than once a day Once a day Every other day Less than 3 times a week
Do you have diarrhea?	Daily At least once a week Occassionally Never
What do you typically eat for BREAKFAST?
What do you eat typically eat for LUNCH?
What do you typically eat for DINNER?
What do you eat for snacks?
What types of beverages do you drink?
How often do you eat out in restaurants?
How often do you eat fast food?
What are your main concerns or goals that you would like to address:
Please feel free to share any additional information you would like me to know:

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