Health History Form - Nourishing Wisdom

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Health History Form

Thank you for your request to schedule your nutrition consultation. Fill out the form below.
If you want to keep a copy, print it out before you click send!

Name:

Session date:

Address

Zip Code

Work Phone

Cell Phone

Home Phone

Email:

Age

Date of Birth

Place of Birth:

Current Weight

Weight Six Months Ago

Weight One Year Ago

Would you like your weight to be different?

Yes
No

If so, how?

Relationship Status

Children?

Occupation

How many hours a week do you work?

Do you sleep well?

Do you wake up a night?

If so, what time(s)?

To urinate?

What time do you generally get up in the mornings?

What time do you generally go to sleep at night?

Any constipation or diarrhea?

Sensitivities or allergies to foods?

Blood Type (if known)

Do you take any herbs/ vitamins / medications regularly?

What percentage of your food is home cooked?

Where do you get the rest from?

Are there any other healers/helpers or therapies with which you are involved?

Yes
No

If so, which? (please list all of them)

Have you had any hospitalizations/surgeries/accidents?

Yes
No

If so, please explain

Do you have sweet cravings?

If yes for what?

Time of day?

How often do you drink coffee?

How often do you smoke?

How often do you eat chocolate?

How often do you drink alcohol?

For Women- Menstrual cycle

How many days is your flow?

How frequent?

Painful or Symptomatic?

Yes
No

Please explain

Are you in menopause?

Yes
No

If yes, how has your transition been?

What are your main health concerns?

How is the health of your mother?

How is the health of your father?

How much television do you watch daily?

Do you take baths?

Do you use a microwave on a regular basis?

Yes
No

Do you use non-toxic home cleaning products?

Yes
No

Do you use non-toxic personal care products (cosmetics, skincare, toothcare……)

What activities do you do that bring you joy?

Do you meditate or have a spiritual practice?

What Foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

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