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Morning Yoga
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Armbar Supreme Clean Bodywash Soap bars (Copy)
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Armbar Supreme Clean Bodywash Soap bars
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The Tropical Soldier Batch
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The Rainbow Warrior Batch
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The Northern Knight Batch
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The Lava-Puhi Batch
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The Milk n’ Honey Batch
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Intro to Snowboarding
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64 ozGlass Waterbottle ( BPA Free )
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30.00
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The Vanilla Gorilla Batch
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The Kaminari Batch
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The Peppermint Batch
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Health History Form
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Personal Information
Name
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First
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Date of Birth
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Day
Year
Age
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Email
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Address
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Health And Wellness Goals
*
What are your health and wellness goals? Why are they important to you?
Personal Health and Family History
Whats the most important thing you'd like to share about your health story?
Do you have any of the Following?
Primary Care Provider
Other Physicians or Specialists
Practioners, Therapists, Healers, etc
Do you have any of the Following?
Primary Care Provider
Other Physicians or Specialists
Practioners, Therapists, Healers, etc.
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Pleast list any supplements or medications you take:
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Have you experienced any barriers or challenges to accessing health care?
Medical diagnoses or conditions:
History of serious illnesses, hospitalizations, injuries, or surgeries:
Family History
Describe the health of your:
Mother:
Father:
Is there anything from your childhood pertaining to your health you'd like to share?
Do you have any other notable family or personal health information you'd like to share?
Physical Health Information
Current Weight:
Height:
How many hours do you sleep per night on average?
How would you describe your quality of sleep?
How is your energy level most days?
1
2
3
4
5
Do you experience any pain, stiffness, or swelling on a regualr basis? If so, please explain:
Metabolic Health
Blood Sugar Imbalances
Elevated Cholesterol
Elevated Blood Pressure
Elevated Triglycerides
Other
Other:
Digestive Health
Bloating
Constipation
Diarrhea
Gas
Nausea
Stomach Pain
Other
Other:
Reproductive Health
Infertility
Irregular Menstrual Cycle
Low Libido
Other
Other:
Hormonal Health
Thyroid Condition
Toxin Exposure
Signs or Symtoms of Hormonal Imbalance
Signs/Symtoms of Hormonal Imbalance (please list)
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Immune Health
Autoimmune Conditions
Frequent Illness or Infection
Low Vitamin D Level
Allergies and Sensitivities (please list)
Other
Other:
Allergies and Sensitivities
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Brain Health
Brain Fog
Difficulty Concentrating
Forgetfullness
Other
Other:
Nutrition Information
What foods did you grow up eating?
How would you describe your past relationship or history with food? Do any specific memories about food or eating come to mind?
Describe your current relationship with food:
Do you have any food allergies or intolerances? If so, please list:
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Do any of the following apply to you? (Check all that apply)
Challenges with Preparing Meals
Challenges with Access to Food
Difficulties Chewing or Swallowing
Poor Appetite
Do you regularly use any of the following? (Check all that apply.)
Alcohol
Tobacco Products
Other
Other:
Do you follow a specific eating approach/practice for personal, health or religious reasons (e.g., vegan, ketogenic, kosher)? If so, please explain:
Typical daily diet
What does a typlical day of eating look like for you? List a few foods/meals and drinks you usually consume in the corresponding categories:
Breakfast
Lunch
Dinner
Snacks
What, if anything, would you like to change about your nutrition?
Mental and Emotional Health Information
How would you describe your overall mental and emotional health?
How do you like to support your mental health?
How do you cope with stress?
Emotions Check in
Using a 1-5 scale (where 1 = never and 5 = always), rate how often you eperience each of the following:
Anger
Excitement
Fear
Joy
Love
Sadness
Stress
Worry
Spiritual Health Information
What rolle does spirituality play in your life, if any?
What are the important relationships in your life?
Is there anything you'd like to share about your social life? If so, please explain:
Who do you live with, if anyone?
How many hours per week do you typically work?
What hobbbies or recreational activities do you enjoy?
What role does movement, including sports, exercise, and physical activity, play in your life?
Additional Comments
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