Health Form Intake Name: Email: Phone: Age: Height: Birthdate: Birthplace: Current weight: Weight six months ago: Would you like your weight to be different? yes no not sure If so, what? Relationship status: Where do youcurrently live? Children and their ages: Pets: Occupation: Hours of work per week: Please list your main health concerns and health goals: Any serious illnesses/hospitalizations/injuries? How is/was the health of your mother? How is/was the health of your father? What blood type are you? How is your sleep? Hours? Any pain, stiffness, or swelling?Describe Constipation/Diarrhea/Gas? Allergies or sensitivities?Please explain: Do you take any supplementsor medications? Please list: What role do sports and exercise play in your life? What foods did youeat often as a child? What is your foodlike these days? Who will be supportive of you to make food and/or lifestyle changes? Do you Cook? What percentage of your food is home-cooked? Do you crave sugar,coffee, cigarettes, or have any major addictions? The most importantthing I should do to improve my health is: Women Only: Are your periods regular?How many days is your flow?How frequent? Painful or symptomatic?Please explain: Reached or approaching menopause? Please explain: Birth control history: Do you experience yeastor urinary tract infections?Please explain: Anything else you'd like to add?