Health History Form - Happy Food

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Health History Form

Please complete this Health History form so I can better support you during your Health Consultation.

1 Personal Info

2 Health Info

3 Eating Habits

Personal Information

Fields marked with a * are required.
Full Name:*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email:*
Home Phone:*
Cell Phone:
Work Phone:
Place of Birth:
Age:
Current Weight:
Goal Weight:
Height:
Relationship Status:
Children:
Occupation:
Hours of Work Per Week:

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Health Information
List Your Health Goals and/or Concerns:
How is Your Father's Health?
How is Your Mother's Health?
Do You Sleep Well? How Many Hours?
Do You Experience Constipation, Diarrhea, or Gas?
Allergies or sensitivities? Please explain:
Are Your Periods Regular? Days of Flow?? (For Women Only)
Do You Take Any Supplements/Medications? Please list:
What Role Does Exercise Play In Your Life?

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Food Information
What Did You Eat As a Child? (Breakfast, Lunch, Dinner, Snacks, Drinks)
What Is Your Food Like These Days? (Breakfast, Lunch, Dinner, Snacks, Drinks)
Will Friends/Family be Supportive of Your Healthy Lifestyle?
Percentage Home Cooked Food?
Where Do You Get The Rest of Your Food?
Anything else you would like to share?
Opt in to Happy Food Health newsletter.
- Yes
Your privacy is very important. Your information will not be shared.
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Phone
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Contact Info

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