Work With Me
Work With Me
Heath History Men
All information will remain confidential.
Would you like your weight to change?
If so, how?
Where do you currently live?
Hours of work per week
List your main health concerns
Other concerns and/or goals
At what point of your life did you feel best?
Any serious illnesses/hospitalizations/injuries
How 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?
How many hours?
Do you wake up at night? If so, why?
Do you experience any:
Do you have:
Allergies or sensitivities (please explain)
Do you take any supplements or medications (list)
Any healers, helpers, or therapies currently using? (list)
What role does sports or exercise play in your life?
List what types of foods you would eat often for breakfast, lunch, dinner, snacks when you where a child.
list what types of foods you eat for breakfast, lunch, dinner and snacks currently.
Will family and/or friends be supportive of your desire to make food/lifestyle changes?
Do you cook?
What percentage of your food is home-cooked?
Where does the rest come from?
Do you crave:
The most important thing I should change about my diet to improve my health is:
Anything else you would like to share?