Health History Form

Please fill this form out to the best of your ability

*(denotes required field)

Name: *

E-Mail Address: *

How often do you check email?

Address:

Home Phone:

Cell Phone:

Age

Height:

Date of Birth:

Place of Birth:

Current Weight:

Weight six months ago:

Weight one year ago:

Would you like your weight to be different? If so, how?

Relationship Status:

Children?

Pets?

Occupation:

Hours of work per week:

Please list your main health concerns:

List any other concerns and/or goals:

At what point in your life did you feel best?

Have you had any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

What is your blood type?

How do you sleep?

Do you wake up at night? If so, why?

Do you have any pain, stiffness or swelling?

Do you have any constipation, diarrhea or gas?

Do you have any allergies or sensitivities?

Please list any medications or supplements you take:

Please list any additional modes of therapies and therapists with which you are involved:

What roles do sports and exercise play in your life?

What foods did you eat often as a child?

What is your food intake like now?

Breakfast:

Lunch

Dinner

Snacks

Beverages

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

Do you cook?

What percentage of your food is home cooked?

What percentage of your food is not home cooked?

Do you crave sugar, coffee, cigarettes or have any addictions not listed?

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

Is there anything else you would like to share?

A BIT ABOUT ME

Hello, my name is Rebecca DeFranc. My passion for nutrition, fitness and wellness stems from a healthy and active childhood. I took a nutrition class in college, and got certified to teach aerobics, but I decided to pursue a career in education. After many years of teaching school, marrying and having three children, I furthered my interest in nutrition by becoming a certified nutrition and wellness coach through The Institute for Integrative Nutrition in New York. I also received my personal training certification through ISSA. My education allows me to combine my passion for teaching, nutrition and wellness. I now have have the extraordinary privilege of sharing my enthusiasm for nutrition and wellness and helping my clients to embrace a healthier lifestyle. To read more, click here.

Health History Form

A BIT ABOUT ME