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HEALTHYNOW HEALTH HISTORY

PLEASE PRINT CLEARLY. YOUR INFORMATION WILL BE KEPT CONFIDENTIAL.

Home phone and cell: 

Age:___________________Date of birth:_____________ Height:___________

Weight now:_________ 6 months ago:___________ 1 year ago:____________

Would you like your weight to be different? _____________________________

If so, what would you like to weigh and why? ____________________________

________________________________________________________________

 

SOCIAL INFORMATION

 

Relationship status: ________________________________________________

Children: ________________________________________________________

Pets: ___________________________________________________________

Partner’s name: _________________________________________________

Your occupation: __________________________________________________

How many hours a week do you work? _________________________________
 

HEALTH INFORMATION

 

Please list your main health concerns: _________________________________

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Please list other health concerns: _____________________________________

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What are your goals when it comes to your health? _______________________

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At what point did you feel your best? ___________________________________

Have you had any serious illnesses or injuries? Please list:

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How is/was the health of your mother? _________________________________

How is/was the health of your father? __________________________________

What is your ancestry? _____________________________________________

How is your sleep? ________________________________________________

How many hours do you sleep and what are your bedtime hours? ____________

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Do you wake up in the night? ________________________________________

Do you wake up rested? ____________________________________________

 

Do you experience any pain, stiffness or swelling anywhere? _____________________

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Constipation/ gas/ diarrhea? _________________________________________

Do you suffer with allergies or sensitivities? ____________________________

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MEDICAL INFORMATION

 

Do you take any medication? If so please list:

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Do you take any supplements? If so please list:

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Do you have any healers, helpers or therapies?

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Do you participate in sports or an exercise program? Please list:

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How many hours a week do you play sports or exercise? __________________

If you do not exercise do you wish to implement a program? ________________


 

NUTRITION

 

Do you cook? ________ If so, what percentage is home cooked? ____________

Where do you get the rest from? ___________________________________________________

 

How do you feel about cooking? ___________________________________________________

 

How many times a day do you eat? ___________________________________

How often do you food shop? ________________________________________

Do you crave sugar, caffeine or any addictive foods? ______________________

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What are your cheat foods? _________________________________________

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Which diets have you tried in the past? _________________________________

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Did it help you lose weight or change your behaviors? _____________________

What were the outcomes? ___________________________________________

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What foods do you typically eat? 

 

Breakfast ________________________________________________________

 

Lunch __________________________________________________________

 

Dinner __________________________________________________________

 

Snacks _________________________________________________________

 

Drinks __________________________________________________________

OUTLOOK

 

Do you have trouble focusing? ___________________________________________

Are you open to new ideas? _____________________________________________

Do you do better when you have a specific plan to follow? ___________________

Are there people around you that are getting in the way of you making changes in your life? ___________________________________________________________

Are you in touch with your body? _________________________________________

 

Where do you get most of your health, diet and exercise information? 

Please circle: 

Friends  Doctor  Parent  Online  Books/Magazines  TV/ news  Social Media

Have you been hospitalized in the last 12 months?
Are you currently suffering from a medical condition, illness, or injury?

Thanks for submitting!