Vibrance Nutrition and Fitness Intake Form

Health History Form


Client Name:    Date:

Address:    City:    State:    Zip:

Email Address:    How often do you check email?    

Telephone - Work:    Home:    Cell:

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?
  If so, what?

Relationship status:    Children?    

Occupation:

How many hours a week do you work?

Do you sleep well?
   Do you wake up at nights?
   What time(s)?

To urinate:    What time do you generally get up in the morning?    

Do you experience constipation/diarrhea?
    If yes, please explain    


What blood type are you?

What is your ancestry?

Women:
Are your periods regular?
    How many days is your flow?    How frequent?

Painful or symptomatic?
    Please explain


Do you take any supplements or medications? If so, which?


Are there any healers, helpers or therapies with which you are involved? Please list:


What role does exercise play in your life ?

Do you drink coffee, smoke cigarettes, or have any major addictions?

What percentage of your food is home cooked ? %   Where do you get the rest from?

Serious illness / hospitalizations / injury


How is the health of your mother?

How is the health of your father?

What is your chief concern?


Other concerns?



What foods did you eat often as a child?

breakfast
   lunch
   dinner
   snacks
   liquids

What about one year ago?

breakfast
   lunch
   dinner
   snacks
   liquids

What's your food like these days?

breakfast
   lunch
   dinner
   snacks
   liquids