awheeloflife.com

For Body Work Therapy, call Kathy at 717-903-8392

For Holistic Health Counseling, call Michelle at 717-512-0077

Health History Form

(*Required)

Full Name:	*	Date:
Street Address:	*	Email Address:	*
City:	*	How often do you check email?
State:	*
Zip:	*
Work Phone:		Cell Phone:
Home Phone:
Age:		Date of Birth:
Height:		Place of Birth:
Current weight:
Weight six months ago?		Would you like your weight to be different?	Yes No
One year ago?		If so, what?
Relationship status:		Children?
Occupation:
How many hours a week do you work?
Do you sleep well?	Yes No
Do you wake up at nights?	Yes No	What time(s)?
To urinate:
What time do you generally get up in the morning?
Do you experience constipation/ diarrhea?	Yes No	If yes, please explain
What blood type are you?
What is your ancestry?
Women:
Are your periods regular?	Yes No	How many days is your flow?
How frequent?		Painful or symptomatic?	Yes No
		Please explain
Do you take any supplements or medications? If so, which?		Are there any healers, helpers or therapies with which you are involved? Please list:
What role does exercise play in your life?		Do you drink coffee, smoke cigarettes, or have any major addictions?
What percentage of your food is home cooked?	%	Where do you get the rest from?
Serious illness/ hospitalizations/ injury
How is the health of your mother?		How is the health of your father?
What is your chief concern?		Other concerns?
What foods did you eat often as a child?
breakfast	lunch	dinner
snacks	liquids
What about one year ago?
breakfast	lunch	dinner
snacks	liquids
What's your food like these days?
breakfast	lunch	dinner
snacks	liquids