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

Male Health History

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

Personal Information

First Name

Last Name

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?

Social Information

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?

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

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

Multiple File Upload

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

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Your Health History Form

Female Health History

Personal Information

Social Information

Health Information

Women's Health

Medical Information

Food Information

Additional Comments

Male Health History

Personal Information

Social Information

Health Information

Medical Information

Food Information

Additional Comments

Your Health Starts Here