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Health History Form

    Health History

    Name:
    Date:
    Home Address:
    Occupation:
    Do you primarily:
    Are you:
    How did you hear about the SHAPE Program?
    What health benefits do you want to achieve with the SHAPE Program?
    If other, Explain?

    Physical Health

    Height:
    Weight:
    Are there any areas of your body that are not functioning optimally?
    If yes, explain:
    On average, how many hours do you sleep per night?
    Do you wake up feeling refreshed?
    Have you ever been hospitalized or had surgery?
    If yes, why and when?
    Have you been diagnosed with any clinical condition or disease?
    If yes, what?
    Have you ever been in a motor vehicle accident?
    If yes, what kind and when?
    Were you evaluated and treated after the accident?
    Have you had any non-vehicle accidents or falls?
    If yes, explain:
    Have you had any imaging performed in the last year?
    Have you had blood work performed in the last year?
    Were your test results in medically normal ranges?
    If no, which results were abnormal?

    Food Health

    Please list the foods you commonly eat for:
    Breakfast:
    Lunch:
    Dinner:
    Snacks:
    How many cups of vegetables do you eat per day?
    What foods do you crave?
    What are some specific goals you have regarding the SHAPE Program?

    Chemical Health

    Do you choose to get annual flu shots?
    Have you used antibiotics in the last year?
    Do you eat wheat products (bread/pasta/crackers/baked goods)?
    If yes, how many servings per day?
    Do you eat refined sugar?
    If yes, how many servings per day?
    Do you ingest artificial sweeteners (Splenda, Aspartame, Equal, diet drinks, gum) ?
    Do you have any food/drink allergies, sensitivities or intolerances?
    If yes, Explain?
    Do you smoke?
    I used it for:
    Are you/have you been exposed to second-hand smoke?
    Do you take probiotics?
    Do you take Vitamin D?
    Do you take Omega-3?
    Other supplements:
    Please list any medications that you take regularly and why:

    Mental/Emotional Health

    Rate the current level of personal stress in your life:
    Rate the current level of relationship stress in your life:
    Rate the current level of health stress in your life:
    Rate the current level of family stress in your life:
    Rate the current level of occupational stress in your life:
    How do you manage the stress in your life?
    I , hereby grant permission to receive a professional and complete physical examination and consultation, including urinalysis and evaluation.
    Signature:
    Date: