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Nutrition & Wellness Coaching

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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 discuss our program

and how working with the Nourishing Roots team could benefit you.

“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. Answers are required on most questions. Respond N/A if something does not apply to you.

Personal Information

First Name

Last Name

Email

Mobile Phone

Other Phone

Address

Date of Birth

Ideal Weight

Height

Current Weight

Blood Pressure

IMPORTANT: Have You Had Blood Labs Done w/in last 12 mos? (IF LONGER THAN 12 MONTHS, YOU WILL NEED TO HAVE MORE RECENT BLOODWORK DONE)

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

Standard Lipid Panel

Fasting Glucose

Vitamin D

If my Blood Labs do NOT have the above information, I understand I will need to have another blood draw to obtain this information. * Required

YES

Yes (just making sure you understand)

IMPORTANT: Are You Experiencing Low Energy, Fatigue, Difficulty Losing Weight, or Suspect Hormone Imbalance? * Required

Yes

No

I understand that if I answered YES above, I will need Blood Labs for a THYROID PANEL AND A HORMONE PANEL (Estradiol, Testosterone, Progesterone, Sex Hormone Binding Globulin) BEFORE beginning the Nourishing Roots Wellness Program

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 and why?

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? * Required

Good

Fair

Bad

Average hours per night?

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? * Required

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 that represents your typical diet.

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

Your message has been received.

Male Health History