High Level Wellness Online

Health History Form

	* Indicates Required Field
*Date:
*Full Name:
Address:
City:
State:
Zip:
*Email:
How often do you check your email?
Work Phone
Home Phone
Cell Phone

HEALTH HISTORY
Age
Height
Date of Birth
Place of Birth
Current weight
Weight 6 months ago
Weight one year ago
Would you like your weight to be different and if so, what...

HOME LIFE
Relationship status
Do you have children?

WORK LIFE
Occupation?
How many hours do you work weekly?

SLEEP PATTERNS
Do you sleep well?
Do you wake up at night? If so, when?
To urinate?
What time do you get up in the morning?

BODY TYPE
Do you experience constipation/diarrhea?	no yes, please explain
Blood type ?
What is your ancestry?

WOMEN ONLY
Are your periods regular?	no, please explain yes
How many days is your flow? How frequent?
Painful or symptomatic?	no yes, please explain

PERSONAL HEALTH
Do you take any vitamins/medications?	no yes, please explain
Please list any other healers, helpers, pets, or therapies with which you are involved?
What role does exercise play in your life?
Do you have any major addictions, drink coffee, or smoke cigarettes?
How is your dental health? Do you have fillings? What kind?
Have you had any serious illness / hospitalizations/injury?	no yes, please explain

FAMILY HEALTH HISTORY
How is the health of your father?
How is the health of your mother?
Do you have siblings? How Many? How is their health?

YOUR TURN
What are your main health concerns?
Other concerns

YOU AND FOOD
What percentage of your food is home cooked ? Where do you get the rest from?

WHAT FOODS DID YOU EAT OFTEN AS A CHILD?
Breakfast
Lunch
Dinner
Snacks
Liquids

WHAT FOODS DID YOU EAT ONE YEAR AGO
Breakfast
Lunch
Dinner
Snacks
Liquids

WHAT IS YOUR FOOD INTAKE LIKE NOW?
Breakfast
Lunch
Dinner
Snacks
Liquids

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Health History Form

HEALTH HISTORY

HOME LIFE

WORK LIFE

SLEEP PATTERNS

BODY TYPE

WOMEN ONLY

PERSONAL HEALTH

FAMILY HEALTH HISTORY

YOUR TURN

YOU AND FOOD

WHAT FOODS DID YOU EAT OFTEN AS A CHILD?

WHAT FOODS DID YOU EAT ONE YEAR AGO

WHAT IS YOUR FOOD INTAKE LIKE NOW?