212.227.8610
info@foodmattersnyc.com
Adult Health History Form
First Name
Last Name
Address
Address L2
City
State
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
AE
AA
AP
Zip Code
Home Phone
Work Phone
Cell Phone
Email
How often do you check email?
Date of Birth
Place of Birth
Age
Current Weight
Would you like your weight to be different?
No
Yes
If so, what?
Weight 6 months ago
One year ago
Height
Relationships status
Single
Married
Divorced
Children?
Occupation
Hours of work per week:
Do you sleep well?
No
Yes
What time do you generally get up in the morning?
Do you wake up at night?
No
Yes
What times?
To urinate?
No
Yes
What blood type are you?
A
B
AB
O
What is your ancestry?
Where you vaccinated as a child?
No
Yes
What role does exercise play in your life?
Do you drink coffee, smoke cigarettes, or have any major addictions?
No
Yes
What percentage of your food is home cooked?
Where do you get the rest from?
Were you breast fed?
No
Yes
What type of birth did you have?
Vaginal
C-Section
Constipation/Diarrhea?
No
Yes
Explain
Do you take any supplements or medications? If so, which?
Are there any healers, helpers or therapies with which you are involved? Please list
Serious illness/ hospitalizations/ injuries?
No
Yes
What is your chief concern?
Other concerns?
How is the health of your mother?
How is the health of your father?
WHAT FOODS DID YOU EAT OFTEN AS A CHILD?
Breakfast
Lunch
Dinner
Snacks
Liquids
WHAT ABOUT ONE YEAR AGO?
Breakfast
Lunch
Dinner
Snacks
Liquids
PLEASE LIST A FIVE DAY FOOD DIARY
Monday
Tuesday
Wednesday
Thursday
Friday
Breakfast
Lunch
Dinner
Snacks
Liquids
