NeuBalance Holistic Health Counseling :: Amanda Broomell


	Contact Me Health History Form
	Contact Information All information provided is kept strictly confidential. No information is shared or used other than for contacting you and designing your personal program. Full Name: First * MI Last * Address Street Address City State Zip E-Mail Email Address * How often do you check your email? Phone Phone Health History All questions are optional. Feel free to provide what you feel comfortable sharing. Keep in mind the more you can provide, the more information I will have to design your personal program. Age Age Date of birth Place of birth Weight / Height Current weight 6 months ago 1 Year ago Height Would you like your weight to be different? Yes No In what way would you like your weight changed Relationships Relationship Status Please explain Children Do you have children? No Yes How Many Work Occupation Hours worked per week Sleep Do you sleep well? Yes No Do you wake up at nights? No Yes What time(s) To urinate? What time do you wake in the morning? Digestion Do you experience indigestion or heartburn after meals? Yes No Do you experience constipation/diarrhea? Yes No If yes please explain Blood Type Blood type Ancestry What is your ancestry? How is the health of your mother? How is the health of your father? Exercise What role does exercise play in your life? Past Illness and Injuries List any serious illnesses / hospitalizations / injuries. Vitamins and Medications Do you take any vitamins/medications? Yes No Please list them Other Alternative Health Involvement Are there any other healers, helpers, or therapies with which you are involved? Yes No Please lsit them Gender Specific Questions The following questions are gender specific. Please select your gender to continue: Male Female Male Female Menstration Are your periods regular? Yes No How many days is your flow How frequent Painful or symptomatic Yes No Please explain Health Concerns What are your main health concerns? Other concerns: Foods What % of your food is home cooked? Where do you get the rest from? Do you drink coffee, smoke cigarettes, or have any major addictions? Yes No Please list them What foods do you eat currently? Breakfast Lunch Dinner Snacks Drinks / Liquids What foods did you eat one year ago? Breakfast Lunch Dinner Snacks Drinks / Liquids What foods did you eat often as a child? Breakfast Lunch Dinner Snacks Drinks / Liquids If you have already scheduled a consultation, please fill out your health history form. If you are an existing client, please fill out your revisit form.