Janelle Gibbs

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Janelle Gibbs

Please fill out this Health History Form and I will contact you to schedule a free Health History.

Name

First Name

Last Name

Email Address

How often do you check your email?

Phone

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Current address

Birthdate

YYYY

Height

Current weight

Weight six months ago

Weight a year ago

Would you like your weight to be different? If so what?

Relationship status

Do you have children?

Do you have pets?

Occupation

Hours of work per week?

Please list your main health concerns

What goals would you like to reach?

At what point in your life did you feel your best?

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 blood type are you?

How is your sleep?

How many hours?

Do you wake up at night? If so why?

Any pain stiffness or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities?

Do you take any supplements or medications? Please list:

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

What role do sports and or exercise play in your life?

Will 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?

Where is the rest from?

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

The most important thing I should do to improve my health is:

Anything else you would like to share?