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Health History Form

Please submit form before the discovery session

All information is confidential. This form is submitted to kristina@mindfulthyroid.com to conduct a health coaching session. I do not sell your information to third parties.
View Privacy Policy for more details.

If you are a human and are seeing this field, please leave it blank.

- Personal -

Date

First Name

Last Name

Phone

Age

Height

Current Weight

Weight 6 Months Ago?

Weight 1 Year Ago?

Would you like your weight to be different? How?

- Social -

Relationship Status (Married, Single, etc.)

Where do you live (City, State)?

Do You have children?

Do you have any pets?

Occupation

Hours of Work or School per week?

- Health -

Please list your Main Health Concerns

At what point in your life did you feel best?

At what point did you begin to feel worse?

How is your Sleep? How many hours per night?

How often do you Exercise? What kinds?

- Medical -

List any Medications/Supplements you are taking

Do you Experience any of the Following Consistently? (select all that apply)

Joint Pain/Stiffness/Swelling
Bloating/Gas/Stomach Pains
Skin rashes/irritation/acne
Chemical/Fragrance Sensitivities
Fatigue
Constipation
Diarrhea
Acid Reflux
Hair Loss
Depression
Anxiety or Panic Attacks

Have you been diagnosed or treated for any of the following conditions? (select all that apply)

Hashimoto's Thyroid
IBS
SIBO (Small Intestine Bacterial Overgrowth)
Candida
Food Allergies/Intolerances

Have you had any serious illnesses/injuries?

Do you have any other illnesses not listed above?

- Nutrition -

List food cravings or addictions

List any known food allergies or intolerances

How much water do you drink daily?

Are you following a specific Diet? Which one?

Do you cook? What percentage is home-cooked?

Where does the rest come from? (Fast food, etc)

What sort of Foods do you typically eat for Breakfast?

What sort of Foods do you typically eat for Lunch?

What sort of Foods do you typically eat for Dinner?

What sort of Foods do you typically eat for Snacks?

- Additional Information -

The most important thing I should do to improve my health is:

Anything else you would like to share?

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