Lifestyle & Health History Questionnaire First NameLast NameDateAgeHow would you describe your present state of health?Very WellHealthyUnhealthyOtherPlease list any medications you've been prescribed or are taking.Do you take all of your medications as prescribed by your healthcare provider?YesNoPlease list any vitamin, mineral, or herbal supplements you're taking.When was the last time you visited a physician and what was the outcome?Have you ever had your cholesterol checked? If so, what was the outcome?Have you ever had your blood sugar checked? If so, what was the outcome?Please list any health conditions you currently have.Please list any major surgeries.Please list any past injuries.Family History - Has anyone in your family been diagnosed with the following:Heart diseaseHigh cholesterolHigh blood pressureCancerDiabetesOsteoperosisWhat are your dietary goals?Are you currently following a diet plan? If so, please explain.Have you ever followed a diet plan? If so, please describe your experience.What do you consider the major issues with your current eating plan?How many glasses of water do you drink per day?What do you drink besides water?Do you have food allergies or intolerances? If so, please explain.Who shops and prepares food in your home?Describe your meals out? How many times a week do you eat out and what do toy like to eat?Do you have any food cravings? If so, please decribe when you get the craving.Do you consume alcohol? If so, how many times per week?Do you consume caffinated beverages? If so, how many times per week?Do you consume tobacco products? If so, how many times per week?Do you participate in any regular physical activity? If so, please decribe type and frequency.Do you have any injuries that may limit your physical activity?Do you have any physical activity restrictions or recommendations from your physician?What are your honest felings about exercise and physical activity?What are some of your favorite physical activities?Do you work? If so, describe your occupation and work scheduleAbout how many hours of sleep do you get each night?Rate your stress level from 1-10. 10 being the greatest stress level.What is most stressful to you right now?Has your appetite been affected by stress?Body weight - Are you interested in...Gaining body weightLosing body weightMaintaining body weightWhat is your current body weight?On a scale of 1-10 How ready are you to adopt healthy habits?Do you have any specific goals for your health and wellness?Submit