MoodFood Health History Name First Name Last Name Address Email Phone Number Referred by Date of Birth MM DD YYYY Place of Birth Age/ Height/ Weight/ Hair Color Occupation/ How many hours do you work per week? Relationship Status/ Any children? Any pets? What are your main health concerns? Any other concerns and/or goals? At what point in your life did you feel your best? Any current or previous serious illnesses, hospitalizations or injuries? Have you had a concussion? When? Have you had a seizure? When? Do you have epilepsy? How is/was your mother's health? How is/was your father's health? What is your ancestry? What is your blood type? How is your sleep? How many hours do you sleep per night? Do you wake up during the night? If so, why? Any pain, stiffness or swelling? Any constipation, diarrhea or gas? How many bowel movements do you have per day? Any allergies or sensitivities? Do you have dental amalgam fillings? How do you exercise? How many hours per week? How do you breathe? Through your nose or your mouth? List all supplements or medications: Are you involved with any healers, helpers, therapies? Thank you!
