Welcome to HealthySelf Nutrition!

Health History Form


Name *
Address *
Phone Number *
Email Address *
How often do you check your email?
Date of Birth
Place of Birth
Height
Current Weight
Weight 6 Months Ago
Weight 1 Year Ago
Would you like to change your weight? If so, how?
Do you sleep well?
Do you wake up at night?
What time do you usually go to bed?
What blood type are you?
Women: Are periods regular?
Do you take any supplements or medications? If so, which:
Do you drink coffee, smoke cigarettes, or have any major addictions?
Any serious illness, hospitalizations or injuries?
What is your chief health concern(s)?
How is the health of your mother?
How is the health of your father?
What percentage of your food is home cooked?
Where do you get the rest of your food?
What foods did you eat often as a child? Please list foods for breakfast, lunch and dinner.
What foods did you eat about one year ago?
What are your foods like at the present?
What is your relationship status?
Do you have any children? If so, how many?
How are your relationships with your friends?
How are your relationships with your family?
Are there any healers, helpers or therapies that you are involved in? Please list:
What role does spirituality play in your life?
Please explain how and how much time you spend nourishing yourself each week:
What role does exercise play in your life?
What did you want to be while growing up?
What would be your ideal career today, if there were no restrictions?
Current occupation:
How many hours/week do you work?
Are you happy with your career? Please explain:
Any additional information you would like to add?