If you're interested in finding out more about holistic health counseling or scheduling a personal consultation,just use the form below to send me, Alex Jamieson, your contact details.
health history form
This information is secure and confidential and
will not be shared with anyone.
PERSONAL AND CONTACT INFO
Full Name:
Address:
City:
State:
Zip:
Email:
How often do you check your email?
Phone
work
home
cell
HEALTH HISTORY
Age
Height
Date of Birth
Place of Birth
Current weight
Weight 6 months ago
Weight one year ago
Would you like your weight to be different and if so, what...
HOME LIFE
Relationship status
Do you have children?
WORK LIFE
What is your occupation?
How many hours do you work weekly?
SLEEP PATTERNS
Do you sleep well?
Do you wake up at nite, and if so, at what times?
To urinate?
What time do you get up in the morning?
Body Type
Do you experience constipation/diarhhea?
yes
no, please explain
What blood type are you?
What is your ancestry?
WOMEN ONLY
Are your periods regular?
yes
no, please explain
How many days is your flow? How frequent?
Painful or symptomatic?
yes, please explain
no
personal health
Do you take any vitamins/medications?
yes, please explain
no
Are there any other healers, helpers, pets, or therapies with which you are involved? Please list
yes, please explain
no
What role does exercise play in your life?
Do you drink coffee, smoke cigarettes, or have any major addictions?
How is your dental health? Do you have fillings? What kind?
Have you had any serious illness / hospitalizations/injury
family health history
How is the health of your father?
How is the health of your mother?
Do you have siblings? How Many? How is their health?
your turn
What are your main health concerns?
Other concerns
you and food
What percentage of your food is home cooked ? % Where do you get the rest from?
