Gender Neutral Health Intake Form Personal InformationName* First Last Email* How often do you check emails?Home Phone*Work Phone:Mobile:Age:Height:Birthdate: MM DD YYYY Place of Birth?Current Weight:Weight six months ago:Weight one year ago:Would you like your weight to be different?:If so, what?:Social InformationRelationship status:Where do you currently live?:Children:Pets:Occupation:Hours of work per week:Health InformationPlease list your main health concerns: Other concerns and/or goals?: At what point in your life did you feel best?: Any serious illnesses/hospitalizations/injuries?: How is/was the health of your mother?: How is/was the health of your father?: What is your ancestry?: What blood type are you?:How is your sleep?:How many hours?:Do you wake up at night?:Why? Any pain, stiffness or swelling?: Constipation/Diarrhea/Gas?: Allergies or sensitivities? Please explain: Medical InformationDo you take any supplements or medications? Please list:. Any healers, helpers or therapies with which you are involved? Please list: What role do sports and exercise play in your life?: Food InformationWhat foods did you eat often as a child?Breakfast: Lunch: Dinner: Snacks: 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 do to improve my health is: Additional CommentsAnything else you would like to share?: Captcha
