Personal Health Assessment - Better Beyond 50

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Health History Form

Health History Form

Please fill out below form to get free health consultation.

Health History Form

PERSONAL INFORMATION

Full Name:

First

Date of Birth:

MM slash DD slash YYYY

Age:

Sex Assigned at Birth:

Gender Identity:

Preferred Pronouns:

Occupation:

Email:

Phone:

Home Address:

Address

Preferred Contact Method:

Phone

Text

Email

Mail

Emergency Contact Name:

Relationship:

Phone:

HEALTH AND WELLNESS GOALS

What are your health and wellness goals? Why are they important to you?

PERSONAL HEALTH AND FAMILY HISTORY

Health Information

What's the most important thing you'd like to share about your health story?

Do you have any of the following? If so, please list:

Primary care provider:

Other physicians or specialists:

Practitioners, therapists, healers, etc.:

Please list any supplements or medications you take:

Have you experienced any barriers or challenges to accessing healthcare?

Medical Information

Do you have any of the following? If so, please list.

Medical diagnoses or conditions:

History of serious illnesses, hospitalizations, injuries, or surgeries:

Family History

Describe the health of your:

Mother:

Father:

Is there anything from your childhood pertaining to your health you'd like to share?

Do you have any other notable family or personal health information you'd like to share?

PHYSICAL HEALTH INFORMATION

Current Weight (gm):

Height (cm):

Sleep:

How many hours do you sleep per night on average?

How would you describe your quality of sleep?

How is your energy level most days?

1 (Very Low)

2 (Low)

3 (Medium)

4 (High)

5 (Very High)

Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain:

Do you have any of the following concerns? (Check all that apply.)

Metabolic health

Sugar

Elevated Blood Pressure

Elevated Cholesterol

Elevated Triglycerides

Other:

Other:

Digestive health

Bloating

Constipation

Diarrhea

Gas

Nausea

Stomach Pain

Other:

Other:

How many bowel movements (on average) do you have per day?

Reproductive health

Infertility

Irregular Menstrual Cycle

Low Libido

Other:

Other:

Hormonal health

Thyroid Condition

Toxin Exposure

Signs or Symptoms of Hormonal Imbalance (please list)

Other:

Immune health

Autoimmune Conditions

Frequent Illness or Infection

Low Vitamin D Level

Allergies and Sensitivities (please list)

Other:

Other:

Brain health

Brain Fog

Difficulty Concentrating

Forgetfulness

Other:

Other:

NUTRITION INFORMATION

What foods did you grow up eating?

How would you describe your past relationship or history with food? Do any specific memories about food or eating come to mind?

Describe your current relationship with food

Do you have any food allergies or intolerances? If so, please list

Do any of the following apply to you? (Check all that apply)

Challenges with Preparing Meals

Challenges with Access to Food

Difficulties Chewing or Swallowing

Poor Appetite

Do you regularly use any of the following? (Check all that apply.)

Alcohol

Tobacco Products

Other Substances:

Other:

Do you follow a specific eating approach/practice for personal, health, or religious reasons (e.g., vegan, ketogenic, kosher)? If so, please explain:

What does a typical day of eating look like for you? List a few foods/meals and drinks you usually consume in the corresponding categories:

Breakfast

Lunch

Dinner

Snacks

What, if anything, would you like to change about your nutrition?

MENTAL AND EMOTIONAL HEALTH INFORMATION

How would you describe your overall mental and emotional health?

How do you like to support your mental health?

How do you cope with stress?

Using a 1-5 scale (where 1 = never and 5 = always), rate how often you experience each of the following:

Anger

1

2

3

4

5

Excitement

1

2

3

4

5

Sadness

1

2

3

4

5

Stress

1

2

3

4

5

Love

1

2

3

4

5

Worry

1

2

3

4

5

Joy

1

2

3

4

5

Fear

1

2

3

4

5

SPIRITUAL HEALTH INFORMATION

What role does spirituality play in your life, if any?

LIFESTYLE INFORMATION

What are the important relationships in your life?

Is there anything you'd like to share about your social life? If so, please explain:

Who do you live with, if anyone?

How many hours per week do you typically work?

What hobbies or recreational activities do you enjoy?

What role does movement, including sports, exercise, and physical activity, play in your life?

ADDITIONAL COMMENTS

Is there anything else you'd like to share?

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CONTACT US

973-224-0777
bbfiftycoaching@gmail.com
www.bbfifty.com

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Better Diet
Better Sleep
Better Energy
Better Mood

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SUPPORT

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Better Diet

Better Sleep

Better Energy

Better Mood

CONTACT US

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support@domainname.com

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