Wufoo

Tender Shoots Health History Form

This form gives me a sense of your overall health background. Please fill it out to the best of your ability. Before we can schedule you for an initial session, you must fill out this form. It will take about 20 minutes of your time. Thank you kindly!

Date MM / DD / YYYY
Name First Last
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Cell Phone ### - ### - ####
Gender
Age
Height
Date of Birth MM / DD / YYYY
Place of Birth
Current Weight
Weight Six Months Ago
Weight One Year Ago
Would you like your weight to be different?
If so, what?
Relationship Status
Have any children?
Do you sleep well?
Do you wake up at night?
What times?
To urinate?
What time do you generally wake up in the morning?
Are you experiencing any Constipation or Diarrhea?
If so, explain.
Any allergies?
What's your blood type?
What is your ancestry?
Ladies only

Nothing personal fellas. You can just skip this section and jump right into "lifestyle stuff".
Are you pregnant?
If so, what's your due date? MM / DD / YYYY
Are your periods regular?
How many days is your flow?
How frequent?

How many days between cycles 28?
Painful or symptomatic?
Please explain
Lifestyle Stuff

Here's the fun part! Please be detailed with your answers.
Any supplements or medications
If so, which ones?
Are you involved in any therapy or healing arts? If so, please explain.
How would you describe your level of energy?

How do you generally feel during the course of the day? Skunky, lethargic, jittery...
What role does exercise play in your life?
Do you drink coffee, smoke, or have any major addictions?
Any serious illness, hospitalization, or injuries?
What is your chief health concern?
How is the health or your mother and father?
Food Stuff

Your intimate relationship with food. Let's talk about it!
What foods do you remember eating as a kid?

List common breakfast, lunch, dinner, and snacks that you ate as a child.
What foods were you eating a year ago?

List common breakfast, lunch, dinner, and snacks that you ate a year ago.
What foods are you eating these days?

List common breakfast, lunch, dinner, and snacks that you are currently enjoying.
Are there any foods you think you should be eating more of?
What foods if any would you like to eliminate from your diet?
Do Not Fill This Out

Wufoo

Tender Shoots Health History Form

Ladies only

Lifestyle Stuff

Food Stuff