Please take your time and fill out the following form completely. The information you share on this form will help Nourish develop a nutrition and wellness program that meets your specific needs. The more information you share, the better your program will match your concerns and goals.

Please be aware! There is no option to save data on this form so you will have to complete it in one sitting. This health history typically takes between 30 and 45 minutes to complete, so be sure to leave yourself enough time.

Personal Information

Name:

Address:

Email:

How often do you check e-mail:

Home Phone:

Cell Phone:

Age:

Birthdate:

Place of Birth:

Height:

Current Weight:

Weight Six Months Ago:

Weight One Year Ago:

Would you like your weight to be differet?

Why or why not?

Social Information

Relationship Status:

Occupation:

How many hours do you work per week?

Children:

Pets:

Will friends and family support your desire to make lifestyle changes? Explain:

Health Information

Please explain your main health concerns:

Please explain any non-health related concerns:

At what point in your life did you feel best?

Explain any serious illnesses, hospitalizations or injuries:

How is (or was) the health of your Mother?

How is (or was) the health of your Father?

Do you sleep well?

Average hours of sleep per night:

Do you ever wakeup in the night?

If so, why?

Do you experience any pain, stiffness or swelling? Explain:

Explain any allergies or sensitivities:

Do you experience constipation, diarrhea or gas? Explain:

Are your periods regular?

How many days is your flow? How much does it vary?

Explain any pain or other symptoms related to your period:

Are you approaching Menopause? If so, do you feel different? How is your energy?

Describe any use of birth control. Has your use changed over time?

Do you experience yeast infections or urinary tract infections? Please explain:

Medical Information

Explain your use of vitamins or other supplements:

Are you on any prescribed medication(s)? If so, explain:

Do you participate in any personal, family or relationship therapy? If so, explain:

What role does exercise play in your life? Explain:

Food Information

What foods did you eat often as a child?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

What foods do you eat often now?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Do you cook? What are you favorite things to make?

What percetage of your food is cooked at home?

Where do you eat when you do not prepare food at home?

Do you crave sugar, coffee, cigarettes, or have any major addictions? Explain:

The most important thing I should change about my diet to improve my health is:

Additional Input

Do you have any questions, comments or concerns about participating in a Nutrition and Wellness Program with Nourish?