HealthyNow Health History

The form is split into different sections. All information filled out is private. |SI| - Social information |HI| - Health information |MI| - Medical information |N| - Nutritional information

First Name

Last Name

Address

Home Phone

Cell Phone

Age

Date of Birth

Height

Weight currently

Your weight 6 months ago

Your weight 12 months ago

Would you like your weight to be different?

If you answered 'yes' to the question above, what would your ideal weight be, and why?

|SI| What's your relationship status?

How many children do you have, if any?

How many pets do you have, if any?

If you have a partner, what is their name?

What is your current occupation?

How many hours a week do you work?

|HI| Please list your main health concerns, if any.

Please list other health concerns, if any.

What are your goals when it comes to your health?

At what point in your life did you feel your best?

Have you ever had any serious injuries or illnesses? Please list.

How is/was the health of your mother

How is/was the health of your father

How is the quality of your sleep?

How many hours of sleep do you typically get per night?

At what time do you go to sleep and wake up?

Do you wake up in the night?

Do you wake up well-rested?

Do you experience and pain, stiffness, or swelling anwhere?

Do you have constipation/gas/diarrhea?

Do you suffer with allergies/sensitivities

|MI| Do you take any medication? If so, please list.

Do you take any supplements? If so, please list.

Do you have any healers, helpers, or therapists?

Do you participate in any sports or an exercise program? Please list.

How many hours a week do you play sports or exercise?

If you do not exercise, to you wish to participate in a program?

|N| Do you cook? If so, approximately what percentage of your diet is home-cooked?

Where do you get the rest of your meals from?

How do you feel about cooking?

How many times a day do you eat?

How often do you shop for food?

Do you crave sugar, caffeine, or any other addictive foods?

What are your cheat foods?

What diets have you tried in the past?

Did such diets help you lose weight or change your behaviors?

What foods do you typically eat at breakfast, lunch and dinner?

Do you have trouble focusing?

Are you open to new ideas?

Do you do better when you have a specific plan to follow?

Are there people around you who get in the way of you making changes?

Where do you get most of your health, diet, and exercise information from?