Health History Form | SolFood Collective

Please submit the form below and I will be in touch with you!

First name

Last name

Phone

Address Line 1

Address Line 2

City

Age

Height

Date of Birth

Current weight? 6 months ago? One year ago?

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

Relationship Status

Where do you currently live?

Occupation/ Hours per week

What is your retirement plan?

Please list your main health concerns

Other concerns and/or goals?

At what point in your life did you feel 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?

How is your sleep? How many hours? Do you wake up at night? Why?

Any pain, stiffness, or swelling? Please explain

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain

Do you take any supplements or medications? Please list

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

What role does exercise play in your life?

What is your energy like?

Do you still feel independent? Please explain

Are you part of a community? Please explain

What foods did you eat often as a child?

What is your food like these days?

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 do you get 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?

Thank you! We’ll be in touch.

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