Health History Questionnaire
All questions contained in this questionnaire are strictly confidential.
Please share whatever information you feel comfortable sharing.
The more I know about you, the better I am able to evaluate your goals and concerns.

* Required fields
Name *
E-mail Address *
Address *
City *
State *
Zipcode *
Phone (Home) *
Phone (Work)
Phone (Cell)
Birthdate *
	Male Female
Relationship Status	Single Partnered Married Divorce Widowed
Height
Children's Names and Ages (If Applicable)
Occupation
How many hours per week do you work?
What time do you go to bed?
What time do you wake up?
Current Weight
Weight 6 Months Ago
Weight 1 Year Ago
Would you like your weight to be different?	Yes No
If yes, what weight would you like to be at?
Are you currently dieting?	Yes No
If yes, what diet are you using?
Have you tried any diets in the past?	Yes No
If yes, which one(s)?
List any medical problems any doctor(s) have diagnosed
Surgeries or Hospitalizations
Are you currently taking any prescription medications?	Yes No
Please list
Are you currently taking any over-the-counter medications?	Yes No
Please list
Are you currently taking any vitamins or supplements?	Yes No
Please list
Do you have food sensitivities or allergies?
Father Living	Yes No
Age
Significant Health Problems
Mother Living	Yes No
Age
Significant Health Problems
Siblings with Significant Health Problems (Living or Deceased)
Stress is a challenge for me	Yes No
I would like to have more energy	Yes No
I am often overwhelmed	Yes No
I don't sleep well	Yes No
I find being organized difficult	Yes No
Cooking meals is a challenge for me	Yes No
Meal planning is a challenge for me	Yes No
Food Shopping is a challenge for me	Yes No
Exercise is a challenge for me	Yes No
WOMEN ONLY (men please scroll down to MEN ONLY)
I still have a period	Yes No
My period is (if applicable)	Heavy Irregular Painful
I am	Pregnant Breastfeeding
I have had a Hysterectomy	Yes No
Do you get up to urinate during the night?	More than once a night Once A Night Occasionally Never
Any hot flashes or sweating at night?	Yes No
Do you have menstrual tension, pain, bloating, irritability or other symptoms at or around the time of your period?	Yes No
How frequently do you have a bowel movement?	More than once a day Once a day Every other day Less than 3 times per week
Do you have diarrhea?	Daily At least once a week Occasionally Never
MEN ONLY
Do you get up to urinate during the night?	More than once a night Once a night Occasionally Never
How frequently do you have a bowel movement?	More than once a day Once a day Every other day Less than 3 times per week
Do you have diarrhea?	Daily At least once a week Occasionally Never
What did you eat for BREAKFAST as a child?
What did you eat for LUNCH as a child?
What did you eat for DINNER as a child?
What did you eat for BREAKFAST 1 year ago?
What did you eat for LUNCH 1 year ago?
What did you eat for DINNER 1 year ago?
What do you eat for BREAKFAST today?
What do you eat for LUNCH today?
What do you eat for DINNER today?
Tell me about your snacking habits.
What 3 things would you like to be doing right now for your health that you are not currently doing?
What are your main health concerns?
What are your greatest nutrition and lifestyle challenges?
What nutrition questions would you like answered?
Do you currently exercise? If so, when? Please describe.
Do you own any exercise equipment?
If you do not exercise, what are your major obstacles?
Do you have major physical limitations? If yes, what are they?
Please feel free to share any additional information you would like me to know.

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