Senior Confidential Health History

Please write or print clearly

Name:
Address:
Email address:
How often do you check email?
Best number to reach you:
Age:
Height:
Date of Birth:
Place of Birth:

Current weight:
Weight six months ago:
One year ago:

Would you like your weight to be different?  Yes No
If so, what?

Relationship status:
Children:
Pets:

Occupation:
Hours of work per week:

Please list your main health concerns:

Other concerns?

At what point in your life did you feel best?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your father?
How is/was the health of your mother?

What is your ancestry?
What blood type are you?

Do you sleep well?
How many hours?

Do you wake up at night?
Why?

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas? Please explain:

Allergies or sensitivities? Please explain:

Do you take any supplements or medications? Please list:

Any healers, helpers or therapies with which you are involved? Please list:

What role does sports and exercise play in your life?

What is your energy like?

Do you still feel independent? Please explain:

Are you part of a community? Please explain:

What foods did you eat often as a child?
Breakfast :
Lunch :
Dinner :
Snacks :
Liquids :

What’s your food like these days?
Breakfast :
Lunch :
Dinner :
Snacks :
Liquids :

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

What percentage of your food is home cooked?
Do you cook?

Where do you get the rest from?

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

The most important thing I should change about my diet to improve my health is:

Anything else you want to share?

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