Health History Intake Form

HEALTH HISTORY

Welcome! I'm looking forward to working along with you for the next 6 months. Take your time with this and be as open and detailed as you can. Here are a few pointers: Try not to worry about what I will think. Don’t judge what comes up for you or edit your thoughts in any way. Nothing is too big or too small to mention - everything applies. It's all part of your life. This is important work. Be as honest with yourself as possible. As always, everything you share is 100% confidential.

Name*
First Last
Phone*
Email*
Birthdate*
What time were you born?
Example: 1:54am (ask your mom or dad if you are unsure!)
What city, state (province), country were you born in?
Share your bloodwork, genetic testing, supplement lists
Upload files: If you have info that you think could help me, help you. Please share 🙂 *all info is confidential
Drop files here or
What's your blood type?
(ask your parents if you are unsure - if possible)
Describe why you registered for My Nutrition 360 - what do you feel is at the core of your problem?*
Please be as descriptive as possible.
Why is this important to you right now?*
Really open up and share why you are inspired to take action now.
Explain your current exercise and recreation habits*
Do you have any main health/nutrition concerns? Please describe in detail.*
What is your definition of acting out with food/eating/exercise? Does this definition of acting out help or hinder your recovery?*
List ALL medicines, drugs and/or supplements you are currently taking.*
Look up the word rationalization in the dictionary. What reasons have you invented to explain or justify your behavior with food/eating/drinking/working out? (be specific for each)*
Do you think you have had trauma or abuse - physical, sexual, mental or emotional? If so, explain.*
What are the current stresses in your life? What are the resulting numbing behaviors you use for these stresses?*
Have you lost control with addictive/obsessive/compulsive behaviors in the past? Have you hit bottom? Explain?
Describe your current diet/eating. Be as descriptive as possible (breakfast, lunch, dinner, snacks, cravings, favorite brands, restaurants, beverages, chocolates, etc)*
Do you have any known food allergies or sensitivities?**
How many times a day do you typically have a bowel movement?*
Answer this question: The most important thing I should change to improve my health is*
What inspires you and lights you up?*
Please share anything else that you think I should know in order to support you fully in this program.

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