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Health History
Please fill out the form below so we can bring you even more support, strategies and techniques to optimize your health. Please fill this out based on your health and habits BEFORE you joined MOVE THINK SMILE.
Health History
Name
*
First
Last
Email
Primary Phone
✓ Valid number
✕ Invalid number
Age
*
Date of Birth
MM slash DD slash YYYY
Place of Birth
Height
*
Current Weight:
*
Weight 6-months ago:
*
Weight 1-year ago:
*
Would you like your weight to be different? If so, how?
Social
Relationship Status:
*
Occupation
*
On average, how many hours to you work per week?
*
Where do you live?
*
Any children?
*
Any pets?
*
General Health
What are your main health concerns & goals?
Any other concerns or goals?
Any current or previous serious illnesses, hospitalizations, or injuries?
How is/was your mother’s health?
How is/was your father’s health?
At what point in your life did you feel your best?
What is your ancestry?
*
Blood Type:
*
How is your sleep?
How many hours do you sleep per night?
*
Do you wake up during the night? If so, why?
Any pain, stiffness, or swelling?
Any allergies or sensitivities?
Medical
List all supplements or medications:
Are you involved with any healers, helpers, or therapies?
What role do sports and/or exercise play in your life?
Food
Will your family and friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?
*
What percentage of your food is home-cooked?
*
Where does your non-home-cooked food come from?
What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snacks
Liquids / Beverages
What foods did you typically eat now?
Breakfast
Lunch
Dinner
Snacks
Liquids / Beverages
Do you crave sugar, coffee, or cigarettes? Or, do you have any other major addictions?
What is the most important thing you should change about your diet to improve your health?
Additional Comments / Goals / Desires
Is there anything else you would like to share?
What improvements have you noticed since joining MOVE THINK SMILE?
Name
This field is for validation purposes and should be left unchanged.
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