Health History Form

All of your information will remain confidential between you and the Health Counselor.

Personal Information

First Name

Middle Name

Last Name

Street

City

State

Zipcode

US Phone

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What is Your Biggest Health Concern?

What is Your Weight?

Do you want your weight to be different?

What do you think your ideal weight is?

What are your favorite foods?

How do you feel when you eat them?

When do you feel your very best?

How is your sleep quality? How many hours?

What is your occupation? Do you enjoy it? How many hours do you work per week?

What does your exercise look like each week?

Please briefly describe your spiritual practice, if any.

How are your menstrual periods? Any pain? How long? How often?

What is your relationship status?

If you have children, what are their names and ages?

If you have pets, what kind and what are their names?

Please click submit and I will be in touch shortly!