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Back
Counting Colors
The Beauty of Blood Sugar Balance
About
Portfolio
Recipe Testing + Photography
Share the Health
Coaching
Resources
Healthified Mag
Healthified Podcast
Gratisfied
Programs
Counting Colors
The Beauty of Blood Sugar Balance
Contact
Confidential
Health History
Name
*
First Name
Last Name
Email Address
*
How often do you check email?
*
Home Phone
(###)
###
####
Mobile Phone
(###)
###
####
Work Phone
(###)
###
####
Age
*
Height
*
Birthdate
*
MM
DD
YYYY
Place of Birth
*
Current weight
*
Weight six months ago
*
Weight one year ago
*
Would you like your weight to be different?
*
If so, what?
Relationship Status
*
Single
In a relationship
Married
Where do you currently live?
*
Do you have children?
*
If so, how many and how old?
Do you have pets?
Occupation
*
Hours of work per week
*
Please list your main health concerns
*
What are your health goals?
*
At what point in your life did you feel best?
*
Any serious hospitalizations or injuries?
*
How is/was the health of your mother?
*
How is/was the health of your father?
*
How is your sleep?
*
How many hours? Do you wake up at night and why?
Any pain, stiffness or swelling?
*
How is your digestion?
*
Constipation/diarrhea/gas?
Allergies or sensitivities?
*
Please explain
Are your periods regular?
How many days is your flow? How frequent?
Are your periods painful or symptomatic?
Please explain
Reached or approaching menopause?
Please explain
Birth control history
Do you experience yeast infections or urinary tract infections?
Please explain
Do you take any supplements or medications?
*
Please list
Are you involved in any other types of therapies or natural healing remedies?
*
What role does exercise play in your life?
*
What does your eating look like these days?
Breakfast
*
Lunch
*
Dinner
*
Snacks
*
Liquids
*
How much water do you drink on a daily basis?
*
Do you cook?
*
What percentage of your food is home cooked?
*
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Where do you get the rest from?
*
What percentage of your diet is real vs. processed food?
*
How are your cravings?
*
Sweet, salty, caffeine, alcohol, non-existent?
How would you describe your relationship with food?
*
Are there any aspects of your life that feel out of balance?
*
(e.g. relationships, career, nutrition, stress)
The most important thing I should do to improve my health is...
*
If you could imagine achieving your health goals, what does that look and feel like?
*
Anything else you would like to share?
Thank you!
