Confidential Health History Form

Name

Email

Address

How often do you check email?

How did you hear about me?

Telephone - Work:

Telephone - Mobile:

Telephone - Home:

What is the best way to contact you?

PhoneEmail

Age:

Date of Birth:

Place of Birth:

Height:

Weight:

What is your Relationship Status?

SingleMarriedDivorcedSeparatedIn a RelationshipEngagedOther

Children? If yes, how many?

What is your Occupation?

How many hours per week do you generally work?

Do you sleep well?

YesNo

What is your ancestry?

Women: Are your periods regular?

YesNo

Painful or symptomatic?

YesNo

Please explain:

Do you take any supplements or medications? If so, which?

Are there any healer’s, helpers or therapies with which you are involved? Please list:

What role does movement play in your life?

Do you drink coffee, smoke cigarettes, or have any major addictions?

Serious illness, hospitalization, injuries?

How is your mother’s health?

How is your father’s health?