Health History Q & A

Health History Q&A

* Indicates required field

Today's Date *

Name *

First

Last

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth/Age *

Place of Birth *

Height *

Weight *

Blood Type *

Relationship Status *

Who's your closest friend and confidant? *

Pets *

Occupation *

Please list your health concerns/objectives in order of importance. *

Children *

Who are the 5 people with whom you feel most connected mentally, emotionally, and or spiritually? *

Are they people with whom you come into contact at least three times per week? *

Hours of work per week *

Other concerns and/or goals *

Do you now, or have you in the past had:
Please elaborate on yes answers in the comments box at the end of this section.

Please list all medication and or nutritional supplement names, dosages, date you started, prescribing doctor and reason for prescribing. *

Medications and Supplements continued. *

History of heart problems, chest pain or stroke, high blood pressure *

Yes No

Chest pain when exercising *

Yes No

Weight/fitness history

Please describe or list your first memories of being conscious of your weight and or body image. Give as much detail as you like. *

First memories of being conscious of food/relationship to food *

Weight one year ago *

Weight six months ago *

Highest weight ever/age *

Lowest weight ever/age *

Were you working out at this time? If so, what type of workouts? *

Were you working out at this time? If so, what types of workouts? *

Diet and Exercise History

What foods did you eat often as a child? *

What diets have you tried in the past? Were they successful? *

What do you currently eat for breakfast? *

What do you currently eat for snacks? *

What, if any, food allergies or sensitivities do you have? Have you ever been tested for allergies? If so, what kind of testing? *

Have you ever tried a combined food and exercise program before? *

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? *

Do you cook? *

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

What do you currently eat for lunch? *

What do you currently eat for dinner? *

What are your favorite/least favorite foods and drinks? *

What other exercise programs have you tried in the past? Did you enjoy them? *

What percentage of your food is home cooked? *

Where do you get the rest from? *

The most important thing I should change about my diet to improve my health is: *

If you have participated in an Optimal Mind Body program or retreat, please list:

Date of program: *

What worked best: *

What you would like to see included in your upcoming program in terms of service, schedule, meetings, etc.: *

What you liked least about the program/what didn't work for you : *

Please rate the below responses on a scale of 1-10. 1 being poorest, 10 being best.
How do you feel:

Physically *

Mentally *

Emotionally *

Quality of energy throughout the day *

Quality of hair: brittle, dull-strong, or shiny *

Mental alertness, ability to focus *

Peacefulness *

Quality of sleep *

Quality of Skin *

Nails *

Happiness *

Satisfaction with life *

Sleep

Do you have trouble falling asleep, staying asleep or both? *

What time do you normally go to bed/wake up? Would you like to go to bed earlier/wake up earlier? If so, what time(s)? *

Elimination:
Frequency 1=1 x a week, 2=2 week, 3=3x week, 7 = 1x day, etc.

Does it have a foul odor? *

Do you need to strain? *

Consistency? Please list the one or two numbers from the chart below that best determine the consistency of your stool. *

Btw-I know these questions may be difficult and gross but they give me a lot of information about the health of your gut and digestion and therefore your overall health.

Please list your intentions/goals below:

Physically: Would you like your weight/body size and/or shape to be different, if so what do you desire? Be as specific as possible noting areas of desired strength, definition, etc. How do you want to feel physically? *

Other: *

Mentally/Emotionally: *

What have been obstacles to achieving these goals in the past: *

Exercise

What activities do you most enjoy/dislike the least:
Put a Y next to those you like the most and an N to those you like the least

Please list all your favorite fitness classes: *

What is your current workout schedule/program? *

Exercise schedule and availability :
During your Optimal Mind Body Program, what are the optimal days and time(s) of day for you to work out?
Please list the time of day and maximum amount of time you have per day (if any) to devote to a workout (s):

MONDAY *

TUESDAY *

WEDNESDAY *

THURSDAY *

FRIDAY *

SATURDAY *

SUNDAY *

Lifestyle

What is the biggest behavioral change you’ve made in your life? *

What do you love and celebrate about yourself? *

What do you appreciate about your life? *

Are you fulfilled at work? *

Do you feel sexually satisfied? Either with a partner or by yourself? *

Do you feel financially healthy? Or is money a stressor in your life? *

What rules do you follow that you wish you could break? *

Is anything keeping you from being the most authentic, vital, you? If so, what is holding you back? *

What's missing from your life? *

Are you in a romantic relationship? If so, are you happy? If not, do you wish you were? *

Do you feel like you're in touch with your life's purpose? *

Do you express yourself creatively? If so, how? If not, do you feel creatively thwarted? Like there's something within you dying to come out? *

If your fairy Godmother could change one thing about your life-what would you wish for? *

Thank you for filling out my Health Q & A form.
You are one step closer to living your Optimal Mind Body life!
XOMB

Submit

HIPAA Compliance. To the extent required by the provisions of the Health Insurance Portability and Accountability Act (HIPAA) and the regulations promulgated thereunder, the parties hereby agree to appropriately safeguard protected health information (PHI) made available to or obtained by either of them pursuant to this Agreement. Without limiting the obligations of either party otherwise set forth in this Agreement or imposed by applicable law, each party agrees to comply with applicable requirements of law relating to PHI and with respect to any task or other activity it performs in connection with this Agreement.