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: _________________________________
________________________________________________________________
Please list other health concerns: _____________________________________
________________________________________________________________
________________________________________________________________
What are your goals when it comes to your health? _______________________
________________________________________________________________
At what point did you feel your best? ___________________________________
Have you had any serious illnesses or injuries? Please list:
________________________________________________________________
________________________________________________________________
________________________________________________________________
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? ____________
________________________________________________________________
Do you wake up in the night? ________________________________________
Do you wake up rested? ____________________________________________
Do you experience any pain, stiffness or swelling anywhere? _____________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Constipation/ gas/ diarrhea? _________________________________________
Do you suffer with allergies or sensitivities? ____________________________
________________________________________________________________
MEDICAL INFORMATION
Do you take any medication? If so please list:
________________________________________________________________
________________________________________________________________
Do you take any supplements? If so please list:
________________________________________________________________
________________________________________________________________
Do you have any healers, helpers or therapies?
________________________________________________________________
Do you participate in sports or an exercise program? Please list:
________________________________________________________________
________________________________________________________________
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? ______________________
________________________________________________________________
What are your cheat foods? _________________________________________
________________________________________________________________
Which diets have you tried in the past? _________________________________
________________________________________________________________
Did it help you lose weight or change your behaviors? _____________________
What were the outcomes? ___________________________________________
________________________________________________________________
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