Client Health History-Adult

Client Health History-Adult

All information is keep highly confidential

Date:Name:Gender:Date of Birth:

Occupation (last 5 yrs):Previous (if more than 5 yrs):

Address:

City:Province/State:Postal/Zip Code:

Home Phone:Work Phone:Mobile Phone:

Email:

Weight:Height:Body fat% (if known):

Family Physician:Phone:

Please list all current and previous diagnosed medical conditions and treatment:

DiagnosisYear:Treatment:

What are your primary health concerns?

What is going to motivate you to stay with a nutritional/fitness program?

• Supportive “check in” phone calls?
• Daily quick motivational and nutritional tips sent by email?
• Access to the Fit n Healthy Website for new recipes, meal-planning ideas, cooking classes (videos) and nutritional advice?
• Just results?

What can make it difficult for you to stay with a nutritional/fitness program?

Do you have a behaviour(s) you think might sabotage your progress?

Are there any events in your life that changed you significantly? If so, explain. Also include if it has been resolved in your mind or not.

Do you exercise? If so, please provide details.

Type of exerciseAverage DurationTimes per week

Please list the amount of outside time you take (list either daily or weekly):

DailyWeekly

List the illnesses (including the age, be as exact as possible) you had as a child (Ear, sinus, throat, urinary tract, kidney, etc.). Include the treatment your received.

IllnessAgeTreatment

List any medications both prescription and over-the-counter, (e.g. vaccinations, birth control pills, Tums, digestive aids, sleeping pills, pain medications, etc) you have taken in the past or currently take. Note what you were treating and how often you took the dosage:

MedicationUsed to Treat*Frequency

*E.g. daily, weekly, as needed

MedicationUsed to Treat*Frequency

*E.g. daily, weekly, as needed

Have you had taken antibiotics in the last 2 years? If so, when and what for?

Did you take a good probiotic either during or after the antibiotic treatment?

Have you ever had Candida (yeast infections)? If so, when and for how long?

Have you had any surgeries? If so, when and for what?

Do you have any known food, environmental, animal, or drug allergies? If so, please list and the treatment(s) you take.

AllergyTreatment/Medication

Are you taking any vitamins or other food supplements? If so, please list them and indicate if they are self-prescribed or recommended by a health practitioner.

Vitamin/SupplementSelf-prescribedPractitioner-prescribed

Do you currently see any other health practitioners such as chiropractic, massage therapy, reflexology, homeopath, naturopath, etc? If so, which?

Menstruating women only:

Age of first mensesDuration of cyclePainful or heavy?

Do you have children? If so, please provide the following info:

Name:Gender:Age:

(Birthing women only): how were your pregnancies? Where they natural or C-Section deliveries?

Please complete the following info relating to your family medical history. Mark whether the condition is present in you (“Self”) and/or relative (identify which) and the approximate date of diagnosis.

ConditionSelf Date of DiagnosisRelative (Which?) Date of Diagnosis

Allergies

Alzheimer’s

Asthma

By Polar

Cancer

Crohn’s

Colitis

Depression

Diabetes type 1

Diabetes type 2

Heart/Circulation

Hypothyroidism

Hyperthyroidism

IBS

MS

Obesity

Osteoporosis

Parkinson’s

Other

How many bowel movements do you have daily? Please list if it is before or after having coffee (if you drink coffee).

What is the general colour of your stools?

Do you generally follow a set routine (e.g. eating, sleeping, working) or does it frequently change?

Do you find time for self care (e.g. nature walks, massages, pleasure reading, long baths, etc)?

Do you find time for play (e.g. recreational sport, quality time with children/grandchildren)?

What time do you usually go to sleep at night?Wake up time?

Do you feel rested?

Do you have any sleep problems? If yes, please elaborate:

Do you smoke?If yes, how many packs/day?

Did you use to smoke?If so, when did you quit?

Do you have any gold and/or mercury amalgam fillings? If yes, how many?

Where, in your mouth are they?

Have you had any taken out? If yes, when?

Did you do a heavy metal detox in conjunction with that?

Have you had any root canals?If yes, when?

Do you chew gum? If yes, how frequently?What brand?

Describe any other dental problems you’ve had:

Have you ever been exposed to toxic environmental substances?

If so, what and when?

How often do you get the cold or flu each year?

Are you on any special diet?If so, what?

What helps determine your food selections?

Taste?

Cost per serving?

Convenience?

Other?

Can you feel when your body is full? If so, do you keep eating or stop?

Are there any foods you feel bother you in any way?

List any food(s) you crave and the time(s) of day you crave them.

How many glasses of the following do you typically drink each day?

Water: Type: Spring?Distilled?Reverse osmosis?Well?

Chlorinated/City?

Decaf coffee?Caffeinated coffee?

Diet soft drinks?Regular soft drinks?

Alcohol?Milk?Tea?Fruit Juices?

How many times per week do you eat in restaurants?

How many times per day do you eat raw foods?

How often do you eat bread?What type is it typically?

How often do you eat pasta?What type is it typically?

Do you typically feel tired/sleepy after meals?

Do you have any symptoms if you skip meals?If so, what?

Michale Hartte BASc (Nutr), NNCP

Fit n Healthy Nutritional Consulting

Phone: 250 718 1653 Email:

Website: fitnhealthynutrition.com