Page 1 of 2
Health History
Let's start with your personal details
*
*
*
*
What country do you live in?
*
What is you age?
*
What is you height
*
What is your current weight
*
Weight 6 months ago
*
Weight 1 year ago
*
Are you looking to change your current weight?
*
If yes, what is your target weight or goal??
*
Social information
Relationship status
*
Children
*
Pets
*
Occupation
*
Hours of work per week
*
Health information
Please list your main health concerns
*
Other concerns and/or goals?
*
At what point in life did you feel best?
*
Any serious injuries/hospitalisations/injuries?
*
How is/was the health of your mother?
*
How is/was the health of your father?
*
What is your ancestry?
*
How is your sleep?
*
How many hours?
*
Do you wake up at night?
*
f yes or sometimes, Why?
*
Any pain, stiffness, or swelling?
*
Constipation/Diarrhea/Gas?
*
Food allergies, intolerances, or sensitivities?
*
Do you take any supplements or medication? Please list
*
What role does physical activity play in you life?
*
What role does physical activity play in you life?
Sedentary – I rarely exercise and spend most of my day sitting (e.g., desk job, little to no physical activity).
Lightly Active – I engage in light physical activities a few times a week (e.g., walking, casual sports, light stretching).
Moderately Active – I exercise regularly, at least 3-4 times a week, with a mix of cardio and strength training.
Very Active – I work out most days of the week, with intense exercise sessions (e.g., running, weightlifting, high-intensity training).
Extremely Active – I’m highly dedicated to physical fitness, exercising daily or multiple times a day with high-intensity workouts, sports, or physical labor.
Diet information
What foods did you eat often as a child
Breakfast
*
Lunch
*
Dinner
*
Snacks
*
What is your diet like these days?
Breakfast
*
Lunch
*
Dinner
*
Snacks
*
How often do you consume alcohol?
*
How often do you consume alcohol?
A
I don’t drink alcohol
B
Occasionally (1-2 drinks per week)
C
Regularly (3-7 drinks per week)
D
Frequently (8+ drinks per week)
Will family and/or frinds be supportive of your desire to make food and lifestyle changes?
*
What percentage of your food is home-cooked?
*
Where do you get the rest from?
*
Do you crave sugar, coffee, cigarettes, or have any major addictions?
*
The most important thing I should change about my diet to improve my health is
*
Anything else you would like to share?
*
Submit
