Health History Intake Form

HEALTH HISTORY

Welcome! I'm looking forward to working along with you for the next 90 days. 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 in our Slack forum- 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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