Health History Form

All of your information will remain confidential between you and Laura and many questions are optional.

Name

How did you hear about me?

How often do you check your email?

Phone Number

Home Phone

Work Phone

Birthday

Place of Birth

Gender

Age

Height

Current weight

Weight six months ago

Weight one year ago

Would you like your weight to be different?

If so, what?

Social Information

Relationship Status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week

Do you consider yourself and extravert or introvert?

Health Information

Please list your main reason for meeting with Laura

Other health concerns and/or goals?

At what point in your life did you feel best?

Any serious illness/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 per night?

Do you wake up at night?

If so, why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain

Medical Information

Do you take any supplements or medications? Please list

Any healers, helpers, or other therapies in which you're involved? Please list.

What role do sports, exercise, or movement play in your life?

For Female Reproductive System

For those with a uterus, are your periods regular?

How many days is your flow?

Painful or symptomatic? Please explain

For those with a uterus, are your periods regular?

Birth control history

Do you experience yeast infections or urinary tract infections? Please explain

Food Information

How would you describe your eating as a child?

What is your food like these days? For 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 consider yourself a slow, moderate, or fast eater?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

The most important thing I should do to improve my health is...

I understand that all appointments require AT LEAST 24 hours notice (business day) for cancellation or rescheduling or I will be charged the full session cost.