Senior Confidential Health History
Please print clearly!
Name: |
Address: |
Email address: |
How often do you check email? |
Best number to reach you: |
Age: |
Height: |
Date of Birth: |
Place of Birth: |
Current weight: |
Weight six months ago: |
One year ago: |
Would you like your weight to be different? |
If so, what? |
Relationship status: |
Children: |
Pets: |
Grandchildren: |
Occupation: |
Hours of work per week: |
What is your retirement plan? |
Please list your main health concerns: |
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Other concerns? |
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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? |
How is/was the health of your father? |
What is your ancestry? |
What blood type are you? |
Do you sleep well? |
How many hours? |
Do you wake up at night? |
Why? |
Any pain, stiffness, or swelling? Please explain: |
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Constipation/Diarrhea/Gas? Please explain: |
Allergies or sensitivities? Please explain: |
Do you take any supplements or medications? Please list: |
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Any healers, helpers or therapies with which you are involved? Please list: |
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What role does exercise play in your life? |
What is your energy like? |
Do you still feel independent? Please explain: |
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Are you part of a community? Please explain: |
What foods did you eat often as a child? |
Breakfast | Lunch | Dinner | Snacks | Liquids | ||||
What’s your food like these days? |
Breakfast | Lunch | Dinner | Snacks | Liquids | ||||
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? |
What percentage of your food is home cooked? |
Do you cook? |
Where do you get the rest from? |
Do you crave sugar, coffee, cigarettes, or have any major addictions? |
The most important thing I should change about my diet to improve my health is: |
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Anything else you want to share? |
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