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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Age:Height: (Ft)Height: (In)Birthdate: Date Format: MM slash DD slash YYYY Place of Birth:Are you considered a Senior Citizen?YesNoJust Barely!GenderMaleFemalePrefer not to defineDo/have you experience/d menstruation?YesNoCurrent Weight: (lbs)Weight 6 months ago: (lbs)Weight 1 year ago: (lbs)Would you like your weight to be different?YesNoUndecidedWhat do you want your weight to be? Social InformationRelationship StatusSingleLong Term Relationship (5+ years)MarriedDivorcedWidowedOtherPlease SpecifyDo you have children?YesNoWhat are their names & ages?NameAge Please use the + symbol to add more linesDo you have grandchildren?YesNoWhat are their names & ages?NameAge Please use the + symbol to add more linesDo you have pets?YesNoWhat 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?YesNoPlease 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?ExcellentGoodFairPoorTerribleOther.How many hours sleep per night do you average?Do you wake up at night?Yes - every nightYes - most nightsYes - sometimesNoNot that I'm aware ofWhy 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?YesNoHow 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?DefinatelyProbablyNeutralProbably NotNot at allI don't knowDo you cook?YesA LittleNoSomeone else cooks for meWhat 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?