Adult Health History

Referred by

First Name

Last Name

Gender

Male
Female

Date of Birth

Age

Address

City

State

Zip / Post Code

Email

Daytime Phone

Evening Phone

Height

Weight

Occupation

Number of hours worked per week

Relationship status

Children

Allergies or sensitivities

What Blood Type (Digestive Chemistry) are you?

What is your ancestory?

How is the health of your mother?

How is the health of your father?

At what point in your life did you feel your best?

Please rank your current health concerns and rate their severity (on a scale of 1 to 10, 10 being the most severe).

Please tell us any additional information or concerns about your health.

Please list any medications you are currently taking and how long you have been taking them (including birth control pills, aspirin, pain medications, etc.).

Do you crave any of the following?

Sugar
Coffee
Cigarettes

Other cravings/addictions:

Do you currently smoke?

Yes
No

If yes, how much?

How long have you smoked?

Do you frequently breath second hand smoke from others who are smoking?

At work
At Home
Neither

What surgeries, operations, traumas, car accidents, etc. have you had?

Have you ever had full body anesthesia (i.e., to remove tonsils, wisdom teeth, etc.)?

Yes
No

Do you have breast implants?

Yes
No

Do you have any other surgical implants or protheses?

Yes
No

If yes, please explain:

Have you had elective surgery (tummy tuck, face-lift, burned off moles, liposuction, laparoscopy, etc)?

Yes
No

If yes, please explain:

Do you have any metal or plastic inside your body (such as pins, clamps, plates, etc)?

Yes
No

If yes, please explain:

Please describe any scars on you body (major and minor).

Do you have pierced ears or other body piercings?

Yes
No

Do you have any tattoos?

Yes
No

Please rate your current stress level (on a scale of 1 to 10, with 10 being the highest stress).

What is the main reason(s) for your stress?

If over level 5, what step(s) are you taking to reduce stress?

Please select dental work you have undergone:

Silver fillings
Composites (tooth-colored)
Extractions
Bridgework
Partial or full dentures
Gold crowns or inlays
Stainless steel crowns or inlayes
Porcelain crowns or inlays
DeGussa porcelain crowns or inlays
Veneers
Root canals
Root canals with EndoCal
Post
Implants
Temporaries
Braces
Bleeding gums
Sensitive teeth
Bad bite
New cavaties

Please indicate how many of the above selected you have had:

Have you had any teeth extracted (wisdom teeth, four bicuspid extraction, etc.)?

Have you had dental surgery (gum surgery, jaw surgery, etc.)?

Do you need further dental work? Please explain:

How is your sleep?

Restful
Restless
Hard to get to sleep
Wake up often
Get up during the night
Bad dreams

Other symptoms:

What time do you usually go to sleep?

Number of hours of sleep per night:

How is your digestion?

Adequate
Poor
Acid reflux
Burp often
Bloating
Burning/Pain in stomach

Other symptoms:

How are you daily urinations?

Every 2 to 3 hours
Too frequent
Sense of urgency
Too small amount
Too large amount
Burning
Dribbling
Up at night several times

Other symptoms:

Frequency:

3 times daily
Once per day
Skip days

Amount:

Normal
Too little
Too large

Consistency:

Normal
Too hard
Very soft
Diarrhea

Color:

Brown
Black
Whitish

Other:

Lots of mucus
Lots of gas
Foul smell

Other symptoms:

Birth control history:

Are you pregnant?

Yes
No

Are you breast-feeding?

Yes
No

Do you have monthly periods?

Yes
No

Date of last menstrual period:

Are you going through menopause?

Yes
No

Have your periods stopped?

Yes
No
Option 3

Have you had a hysterectomy?

Yes
No
Option 3

If so, when?

Are your monthly periods regular (28 day cycles)?

Yes
No
Option 3

Number of days of your menstrual flow:

Check any symptom(s) you experience associated with your period:

Cramping
Bloating
Feeling weak
Mood swings
Cravings
Heavy bleeding
Back pain
Headaches
Bright red blood
Dark clotty blood

Other menstrual symptoms:

Do you experience yeast infections or urinary tract infections?

Yes
No

What kind of exercise do you do?

How often?

For how long at a time?

Amount of natural sunlight you receive daily outside:

Amount of sunlight you receive daily through windows:

Hours spent daily under fluorescent light:

Do you wear contact lenses?

Yes
No

Do you wear glasses?

Yes
No

If yes, how many hours per day?

Do your lenses have tints?

Option 1
Option 2
Option 3

Do your lenses have anti-glare coating?

Yes
No

Do your lenses have scratch resistant coating?

Yes
No

Watching TV:

Working on a computer:

Talking on a phone:

Talking on a cellular phone:

Wearing a pager:

Wearing a headset:

Wearing a wrist-watch (with battery):

Wearing a hearing aid:

Riding in a car/truck/vehicle:

Near electrical equipment for long periods of time (such as copy machines, high power lines, computers, etc):

When you sleep, is your head within 10 feet of a plug-in clock (such as on a nightstand)?

Yes
No

Please check which of the following you use:

Shampoo
Shaving cream
Deodorant
Toothpaste
Soap
Hair permanent
Hand/body lotion
Facial cleanser/moisturizer
Hair spray/gel
Fingernail/toenail polish
Face make-up/eye make-up
Perfumes/cologne
Personal (sexual) lubricant
Contraceptive jelly/spermacide
Laundry soap
Dish washing liquid/powder
Tub/tile cleaner
Glass cleaner
All purpose cleaner
Toilet freshener
Roach/ant spray
Other chemical exposure (from yard work, workplace, art, etc)

Please check which one of the following you use:

Gas stove
Electric stove
Electric heater
Electric blanket
Water bed
Turbo blend
Microwave oven
Air purifier
Water purifier

Please indicate the type of any air purifier/water purifier you use?

What type of cookware do you use?

Stainless steel
Aluminum
Iron
Teflon-coated
Glass
Titanium 316

Other cookware:

What type of shower filter do you use (for chlorine protection)?

When was your filter last changed?

Do you have pets?

Yes
No

If so, what kind/how many?

Are pets allowed in the house?

Yes
No

Are pets allowed on your bed?

Yes
No

What do you feed your pet?

Pre-made foods:

Canned food
Boxed cereals
Frozen dinners
Bottled or frozen juices
Take-out food

Red meat (beef, pork, lamb):

Commercially grown
Naturally raised

Chicken:

Commercially grown
Naturally raised

Turkey:

Commercially grown
Naturally raised

Fish:

Fresh fish
Frozen fish
At a restaurant
Canned tuna

Fresh vegetables:

Commercially grown (store bought)
Organically grown (store bought)
Organically grown (direct from farmer)

Fresh fruit:

Commercially grown (store bought)
Organically grown (store bought)
Organically grown (direct from farmer)

Whole grains:

Commercially grown (store bought)
Organically grown (store bought)
Organically grown (direct from farmer)

Whole beans:

Commercially grown (store bought)
Organically grown (store bought)
Organically grown (direct from farmer)

Eggs/Butter:

Commercial eggs (store bought)
Naturally grown eggs
Commercial butter
Natural butter

Milk:

Commercial milk
Organic pasteurized milk
Organic goats milk
Good quality, raw whole milk

Cheese:

Commercial cheese
Organic cheese (store bought)
Aged cheese

Condiments:

Commercial salt and/or pepper
Pink salt (PRL)
Artificial sweeteners (Equal, Sweet 'N Low, Coffeemate, etc)
Commercial ketchup or mustard
Commercial vinegar
Commercial olive oil
PRL olive oil
Other PRL oils

Do you eat at restaurants?

Yes
No

If yes, how often?

Where?

What type of food do you eat at restaurants?

Do you prepare meals at home?

Yes
No

If so, how often?

What type of food do you prepare?

Do you:

Skip meals often
Have irregular eating times
Eat food past 7pm

Do you avoid food/drink that list "natural flavors" (which means hidden MSG) on the label?

Do you drink tap water?

Yes
No

If you have a home-water purifier, when was the last cartridge change?

What brand of drinking water do you use?

Breakfast (Identify typical time eaten):

Lunch (Identify typical time eaten):

Dinner (Identify typical time eaten):

Snacks (Identify typical time eaten):

What type of sheets and blankets do you use (i.e., 100% cotton, silk, polyester, ploy-blends, wool, etc)?

What type of pillow do you use?

What type of mattress do you sleep on (such as box springs, synthetic, futon, latex, etc)?

What direction does the top of your head point when you sleep (i.e., south, north, northwest, etc)?

Do you sleep with the curtains drawn tightly (so the room is very dark) or is there considerable light in the room when you sleep?

Is there a computer, TV or electrical appliance near your bed?

If so, how far away?

Are any electrical appliances left on in the room when you sleep (such as a TV or computer)?

Do you sleep with a clock-radio near your bed (within 1 to 2 feet)?

Do you sleep near a window?

If yes, what direction does the window face?

Do you sleep with a whole-house alarm turned on (which uses infrared beams/sensors within the house)?

Do you sleep with your head at least 1 foot away from the wall?

Have you ever received acupuncture treatments?

If so, how many treatments?

For what purpose?

Do you wear a hearing aid?

Yes
No

If yes, which ear(s)?

Do you wear a battery-operated watch?

Yes
No

Do you wear a pacemaker?

Yes
No

Do you wear any other electrically-powered device on your body?

Yes
No

If yes, what and where?

Do you use a cell phone?

Yes
No

If yes, how often?

Do you live or work within 1/2 mile of a cell phone tower?

Yes
No

Do you live or work within 100 feet or less of a power transformer (on a telephone pole)?

Yes
No

Do you wear a pager?

Yes
No

If yes, how often?

Do you wear fingernail or toenail polish?

Yes
No

Have you ever worn fingernail or toenail polish?

Yes
No

If yes, for how long?

Have you ever had toxic chemicals spill on your body?

Yes
No

If yes, what?

Have you received the smallpox vaccine?

Yes
No

Have you taken oral polio vaccine?

Yes
No

Do you want to lose weight?

Yes
No

If so, how much?

How important is your health to you, on a scale from 1 to 10 (1 is the lowest; 10 is the highest)?

How much confidence do you have in medical drugs, on a scale from 1 to 10 (1 is the lowest; 10 is the highest)?

How much confidence do you have in your body's ability to heal itself (if given the right nutrients/natural therapies), on a scale from 1 to 10 (1 is the lowest; 10 is the highest)?

List any nutritional supplements that you regularly take:

List any healers, helpers or therapies in which you are involved:

What best describes your diet overall? (check all that apply)

Mostly eat out (fast food)
Mostly eat out (but try to eat healthier items)
Eat whatever is available
Occasional binges
Would never give up meat
Eat a lot of fresh food (very little from cans, boxes)
Mostly homemade meals
Vegetarian
Eat mostly organic
Eat a lot of raw food
In transition to eating better

What are your specific health goals (what do you really want)?

In your opinion, what is the most important thing you should do to improve your health?

How far are you willing to commit to achieve your health goals?

Don't really want to change much
Willing to change some
Willing to change a reasonable amount
Willing to do whatever it takes

How much money do you spend per month on your health, out-of-pocket?

How long do you want to live (check all that apply)?

Age 60 to 70
Age 70 to 80
Age 80 to 90
Age 90 to 100
Age 100+
As long as I am healthy
As long as I have been granted
Until I complete my mission (purpose on earth)
Only if my significant other is still alive also
Forever
It's already enough

Anything else you would like to share:

Please complete the following questions carefully. This information will help us to build a specialized nutritional program, personally designed for you.

All information listed will remain confidential between client and health coach.

Personal Information

Health Challenge(s)

Other Information

Medications

Cravings

Smoking

Surgeries

Scars

Stress

Dental Work

Health Overview

For the following questions, please check the phrases that apply to you:

Sleep

Digestion

Urination

Bowels

Women Only

Menstrual Cycle

Exercise

Sunlight

Eyewear

Electromagnetic Exposure

How many hours do you spend daily with the following devices:

Personal Care Products

Appliances

Cookware

Shower filter

Pets

Food Choices

Please check each type of food that you eat often (once a week or more):

Food Habits

Eating Out

Home Meals

Meal Habits

MSG

Water

Typical Diet

Bedroom/Sleep Considerations

Bedding Materials

Mattress

Head Direction

Darkness

Electronic Appliances

Clock Radio

Windows

Alarm

EMF Exposure

Previous Treatments

Electrical Devices Worn on Body

EMF Exposure

Toxic Body Exposure

Vaccinations

Personal Health Goals