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Your Health Starts Here

Your Health History Form

Please note: When we receive your completed health history,

we will contact you to schedule your initial consultation with the Nourishing Roots team.

“Health is a state of complete harmony of the body, mind and spirit.

When one is free from physical disabilities and mental distractions, the gates of the soul open.”

– B.K.S. Iyengar

Female Health History

All of your information will remain confidential between you and the Nourishing Roots Team.

Personal Information

First Name

Last Name

Email

Mobile Phone

Other Phone

Address

Date of Birth

Height

Current Weight

Ideal Weight

Blood Pressure

Have You Had Blood Work Done w/in last 12 months?

To Avoid Delays in Scheduling - Please Check That Your Blood Labs Have These Basic Bloodwork Panels: * Required

Lipid Panel

Fasting Glucose

Vitamin D

If You Are Experiencing Low Energy, Fatigue, Difficulty Losing Weight, or Suspect Hormone Imbalance, Please Have the Following Bloodwork Also:

Thyroid Panel

Hormone Panel (Estradiol, Testosterone, Progesterone, Sex Hormone Binding Globulin)

Social Information

How did you hear about Nourishing Roots?

Relationship Status

Occupation

Children

Hours of Work Per Week

Pets

Day to day, what emotions do you most commonly feel?

Health Information

Please list your main health goals:

Other health concerns and goals?

At what point in your life did you feel your best?

Any serious illnesses/diagnoses/surgeries/injuries and past hospitalizations?

How is/was the health of your mother?

How is/was the health of your father?

How is your sleep?

Good

Bad

How many hours?

Do you wake up at night?

What factors affect your sleep?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities?

Women's Health

Are your periods regular?

Yes

No

n/a

How many days is your flow?

Painful or symptomatic?

Reached or approaching menopause?

Birth control history:

Do you experience yeast infections or urinary tract infections?

Medical Information

Do you take any supplements or medications?

Any healers, helpers, or therapists with which you are CURRENTLY involved?

Any healers, helpers, or therapists you have worked with in the PAST?

What role do sports and exercise play in your life?

Food Information

List the food you ate for one day in the past week.

Select an option

Yes

No

Occasionally

What % of your food is home-cooked?

Where do you get the rest from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

The most important thing I should do to improve my health is:

Additional Comments

Anything else you would like to share?

Upload File

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Multiple File Upload

I declare that the info I’ve provided is accurate & complete

Your message has been received.

Male Health History