Holistic Wellness Contact Form
    Please complete entire form before submitting.  Thank You

Address:

Food Analysis Health History

Home Telephone                           Cell #:

Age:                     Height:                          Date of Birth:

Current weight:                 Weight six months ago:                          One year ago:

Would you like your weight to be different?                           If so, what?

Relationship status:                     Children?

Occupation:

Hours of work per week:

Please list your main health concerns:

 

Any serious illness/hospitalizations/injuries/

Allergies?

Any Foods you truly dislike?

What is your ancestry?

What blood type are you?

Do you sleep well?                 How many hours?              Do you wake up at night?

Why do you wake up?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?                Explain:

 

Do you take any supplements or medications? Please list:

 

What role do sports and exercise play in your life?

What were your favorite foods you ate often as a child?

Do you eat Breakfast every day?                   Most days?             Not at all.

What percentage of your food is home cooked?

What percentage is not?

Where do you get the rest from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

What are they?

Anything else you would like to share?  

 

 

 

Please provide a convenient day and time to meet and discuss your health history once your payment is received.