Health History

Your Health History Form:

Congratulations on taking the first step towards preventive health care through nutrition. This form and the evaluation of your history is complimentary by a registered nurse and is completely confidential.

My goal is to work with each client’s bio individuality using my skills as an RN and Health Coach to assist them in reaching their personal health goals.

You will be empowered not deprived. You will be given many tools, support and motivation.

Review our services and consider which program best meets your needs.

Thank you,

Deborah McNabb R.N.

Your Name (required)

Your Email (required)

Your Phone (required)

Your Address (required)

Your Age

Your Height

Your Weight

Your Date of Birth

Your Place of Birth

Your Weight 6 Months Ago

Your Weight 1 Year Ago

Would you like your weight to be different?
 Yes No

What would you like your weight to be?

What is your current relationship status?

What is your occupation?

How many children do you have?

How many hours do you work per week?


What are your main health concerns?

Do you have any other concerns or goals?

At what point in life did you feel best?

Any serious illness or injury?

How is/ was the health of your mother?

How is/was the health of your father?

What is your ancestry?

What is blood type?

Do you wake up at night?
 Yes No

Any pain stiffness or swelling?
 Yes No

Are your periods regular?
 Yes No

How many days is your flow?

How frequent?

Reached or approaching menopause? (please explain)

Birth Control?
 Yes No

Do you experience any yeast infections or urinary tract infections? (please explain)

Constipation diarrhea gas? (please explain)

Do you have allergies or sensitivities? (please explain)

Do you take meds or supplements? (please explain)

What role does exercise play in your life? (please explain)

What foods did you eat often as a child?
, , ,

What foods did you eat now?
, , ,

Will family and friends be supportive of your desire to make food
and or lifestyle changes? (please explain)

What percentage of your food is home cooked?

Do you cook?
 Yes No

Where do you get the remainder of your food from?

Do you experience cravings? (please explain)

What do you believe is the most important thing you should change about your diet to
improve your health?

Anything else you would like to share?

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