Health History Form The information you provide below will give me a better understanding of your wants and needs. Please answer as best you can, and I look forward to discussing with you further!Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number (Optional)Please list your main health concerns:Please list your health goals:Do your family and friends support you in your health goals?YesNoOn average, how many hours of sleep do you get a night?Do you wake up during the night frequently?Do you suffer from any of the following?:PainStiffnessSwellingConstipationDiarrheaGas/BloatingAllergiesSensitivitiesIf you checked any of the above, please explain:What role does sports and exercise have in your life?Do you take any supplements or medications? Please list below.Any healers, helpers or therapies with which you are involved in?What do you typically eat and drink for breakfast, lunch, dinner and snacks? How much of your food is home cooked?Where does the rest come from?Do you crave sugar, coffee, cigarettes or have any major addictions?The most important thing I should change about my diet to improve my health is:Anything else you would like to share?CommentSubmit
