Health History Form

First Name

Last Name

Address

Date of Birth

Do you currently take any prescribed or over the counter medications?

Do you have any allergies to foods or medication?

Do you take supplements on a daily basis? Please list them below.

Have you ever been diagnosed with asthma, seizures or anemia? If yes, please explain.

Have you ever been diagnosed with pre-diabetes, PCOS, diabetes, high fasting blood glucose or metabolic disease? If yes, please explain.

Have you every been diagnosed with heart disease, high blood pressure or any other heart-related disorders? If yes, please explain.

Any liver or kidney issues?

Do you have a history of disordered eating patterns or an eating disorder?

Do you receive regular check-ups and blood testing?

Please list any prior injuries or surgeries.

For female clients--please state if you menstruate regularly or if you are menopausal/post-menopausal.

Anything else you'd like to share?

Thanks for submitting!