Alternative Health Visions

Health History - 1

First Name
Middle Name
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
Daytime Phone	() -
Evening Phone	() -
E-mail Address
How often do you check email?
Age:
Height:
Date of Birth:
Place of Birth:
Current weight:
Weight six months ago:
One year ago:
Would you like your weight to be different?
If so, what?
Relationships status:
Children?
Occupation:
Hours of work per week:
Do you sleep well?
Do you wake up at night?
What times?
To urinate?
What time do you generally get up in the morning?
Constipation/Diarrhea?
Explain:
What blood type are you?
What is your ancestry?
Women: Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic?
Please explain:
Do you take any supplements or medications? If so, which?
Are there any healers, helpers or therapies with which you are involved? Please list:
What role does exercise play in your life?
Do you drink coffee, smoke cigarettes, or have any major addictions?
What percentage of your food is home cooked?
Where do you get the rest from?
Serious illness/ hospitalizations/ injuries?
What is your chief concern?
Other concerns?
How is the health of your mother?
How is the health of your father?

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Phone: 732-371-4926

Whole Nutrition for Life