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My Roots
Functional Nutrition
Yoga Instruction
Events
Notebook
Contact
Cart
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My Roots
Functional Nutrition
Yoga Instruction
Events
Notebook
Contact
HEALTH HISTORY
Name
*
First Name
Last Name
Email Address | Phone Number
*
Address
Relationship Status | Occupation | Hours of work per week
Gender | Birthday | Weight | Height
Main causes of stress in your life?
What are your main health concerns?
At what point in your life did you feel the best and why?
Any serious illness/hospitalizations/injuries?
How is/was the health of your father and mother?
What is your blood type? Do you have allergies/sensitivities?
How is your sleep? How many hours of sleep per night? Do you wake up at night/ why?
If you menstruate, how is your cycle overall? Do you experience pain or PMS? Birth control history + practice?
What supplements/medications do you take regularly?
How are your energy levels throughout the day?
How is your digestion / bowel movements?
Do you suffer from regular pain?
What is your relationship with your body like?
What is your exercise or movement routine?
Do you experience food cravings, if so, what kinds of food do you crave?
Do you classify under a specific dietary theory?(ie; vegetarian, vegan, paleo, etc.) ?
Do you cook at home? If so, what do you typically cook? How often do you cook at home?
What were your meals like as a kid?
What is an average day of eating like for you now?
What liquids do you take in daily / How much?
Alcohol or drug consumption / How much?
Do you currently take part in any form of healing or therapy?
How do you want to feel?
Is there a topic you would like to not be asked about?
Anything else that you would like to share?
Thank you!
REVISIT FORM
Name
*
First Name
Last Name
Email Address
*
What are the top three positive changes you've noticed since our last session?
*
What are your main concerns or challenges?
What is your greatest victory right now?
Any changes with your sleep?
Any changes with your mood or energy?
How is your digestion + bowel movements?
Have you changed your medications/supplements?
What foods have you been eating more of? Any difference in cravings?
Anything else would you like to share with me?
Thank you!
