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Health History Form

Personal Information
Name
First Last
Email
How often do you check email?
Phone
Age
Date of Birth
DD slash MM slash YYYY
Place of Birth
Height
Current Weight
Weight Six Months Ago
Weight One Year Ago
Would you like your weight to be different?
- Yes
- No
If so, what?
Social Information
Relationship Status
Where do you currently live?
What is your living arrangements?
Do you have children? If so what are their names and ages?
Do you have pets? If so what are their names and type?
Occupation
Hour of work per week
Health Information
Please list your main health concerns
Other concerns and/or goals?
At what point in your life did you feel your best?
Any serious illnesses/hospitalizations/injuries?
How is/was the health of your mother?
How is/was the health of your father?
What was your birth like?
What is your ancestry?
What blood type are you?
How is your sleep? How many hours do you sleep? Do you wake up at night? Why?
Any pain, stiffness, or swelling?
Constipation/Diarrhea/Gas?
Allergies or sensitivities? Please explain:
Medical Information
Do you take any supplements or medications? Please list:
Any healers, helpers, or therapies with which you are involved? Please list:
What role does sports and exercise play in your life?
Food Information - What foods did you eat as CHILD?
Breakfast
Lunch
Dinner
Snacks
Liquids
Food Information - What is your food like these days?
Breakfast
Lunch
Dinner
Snacks
Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook? What percentage of your food is home-cooked?
Where do you get the rest 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:
Additional Comments
Anything else you would like to share?

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Email

hello@zestforlife.africa

Contact

+27 72 211 5508

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