Health History Share your history so we can help you get healthy! Step 1 of 6 16% Personal InformationName First Last Email How often do you check email? Phone: HomeWorkMobileAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Age:Height: (Ft)Height: (In)Birthdate: MM slash DD slash YYYY Place of Birth: Are you considered a Senior Citizen? Yes No Just Barely! Gender Male Female Prefer not to define Do/have you experience/d menstruation? Yes No Current Weight: (lbs)Weight 6 months ago: (lbs)Weight 1 year ago: (lbs)Would you like your weight to be different? Yes No Undecided What do you want your weight to be? Social InformationRelationship Status Single Long Term Relationship (5+ years) Married Divorced Widowed Other Please Specify Do you have children? Yes No What are their names & ages?NameAge Please use the + symbol to add more linesDo you have grandchildren? Yes No What are their names & ages?NameAge Please use the + symbol to add more linesDo you have pets? Yes No What are their names & ages?NameAge Please use the + symbol to add more linesWhat is your occupation? How many hours a week do you work? Health InformationPlease list your main health concerns.Do you have any other concerns/goals?At what point in your life did you feel the best? Have you had any serious illnesses/hospitalizations/injuries? Yes No Please elaborateHow is/was the health of your mother? How is/was the health of your father? What is your ancestry? What blood type are you? How is your sleep? Excellent Good Fair Poor Terrible Other. How many hours sleep per night do you average?Do you wake up at night? Yes - every night Yes - most nights Yes - sometimes No Not that I'm aware of Why do you wake up? Do you have any of the following? Pain Stiffness Swelling Constipation Diarrhea Gas Allergies/Sensitivities Please explain. Women's HealthAre your periods regular? Yes No How many days is your flow?How frequent? Are your periods painful or symptomatic?Please explain. Have you reached or are you approaching menopause?Please explain. What is your birth control history? Do you experience yeast infections or urinary tract infections?Please explain. Medical InformationDo you take any supplements or medications?Please list using the + symbol Do you any healers, helpers, or therapies with which you are involved?Please list using the + symbol What role does sports and exercise play in your life?What is your energy like? Do you still feel independent?Please explain.Are you part of a community?Please explain. Food InformationWhat foods did you often eat as a child?Use the + symbol to add more linesBreakfastLunchDinnerSnacksLiquids What is your food like these days?Use the + symbol to add more linesBreakfastLunchDinnerSnacksLiquids Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Definately Probably Neutral Probably Not Not at all I don't know Do you cook? Yes A Little No Someone else cooks for me What percentage of your food is home-cooked?Where do you get the rest from? Do you crave sugar, coffee, cigarettes, or have any major addictions?The most important thing I should change about my diet to improve my health is:Additional Comments:Anything else you would like to share?