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Fill The Child Health Form Below
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Personal Information
Name
*
First
Last
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Email
*
Phone
*
How often do you check emails?
Height
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Date Of Birth
*
Current Weight
*
Age
*
Weight 6 Months Ago
Place Of Birth
*
One Year Ago
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Would you like your weight to be different?
Yes
No
If so, what?
How is your Oral Health (Teeth, Gums, Tongue etc.,)
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Social Information
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Relationship Status
*
Married
Unmarried
Number Of Children
Occupation
*
Where do you currently live?
*
Pets
Hours of work per week
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Health Information
Please list your main health concerns *
*
Other concerns and/or goals?
At what point in your life did you feel best?
Any serious illnesses/hospitalizations/injuries?
*
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How is/was the health of your mother?
What is your ancestry?
How is your sleep?
Do you wake up at night?
Any pain, stiffness, or swelling?
How is/was the health of your father?
What blood type are you?
How many hours?
Why?
Constipation/Diarrhoea/Gas?
Allergies or sensitivities? Please explain
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Medical Information
Do you take any supplements or medications? Please list
*
Any healers, helpers, or therapies with which you are involved? Please list
What role do sports and exercise play in your life?
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Food Information
What foods did you eat often as a child? Please list
What is your food like these days?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
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Do you cook ?
Yes
No
Where do you get the rest from?
What percentage of your food is home-cooked?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is
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Additional Information
Anything else you would like to share?
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