HEALTH HISTORY FORM
Name:_______________________________ What do you like to be called?__________
Full Address, City, State, Zip:________________________________________________
________________________________________________________________________
May we send mail to this address? _____
Best Contact Number(s): ___________________________________________________
May we leave messages at this number? _____
Email Address:______________________________ (Handouts for sessions will be sent to the
email address you provide.)
Age: _____ Height: _____ Date of Birth: ___________Place of Birth: _______________
Current Weight: _______ Weight 6 Months Ago: _______ Weight 1 Year Ago: _______
Would you like your current weight to be different? If so, what? ___________________
Relationship Status: ___________________ Children: ___________________________
Pets:____________________________________ Occupation: ____________________
Hours of work per week: ________ Hobbies: ___________________________________
Top 5 things you would like to change in order of importance to YOU (please be specific):
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
At what point in your life did you feel your best and why?
________________________________________________________________________
Any diagnosed illnesses/hospitalizations/injuries?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Ancestry: ______________________________ Blood Type: __________
Do you sleep well? _______ How many hours? _______ Do you wake up at night? ____
If yes, why? _____________________________________________________________
Any pain, stiffness, or swelling? _____________________________________________
Constipation, diarrhea, gas, heartburn, irregularity, or indigestion? Please explain:
________________________________________________________________________
________________________________________________________________________
Allergies or sensitivities (including environmental, food, and drugs)? Please explain:
________________________________________________________________________
________________________________________________________________________
Supplements and/or medications:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Involved with any other alternative healers or therapists?
________________________________________________________________________
What role do sports and/or exercise play in your life?
________________________________________________________________________
Please list your typical daily diet:
Breakfast: _______________________________________________________________
Lunch: _________________________________________________________________
Dinner: _________________________________________________________________
Snacks: _________________________________________________________________
Liquids: ________________________________________________________________
What percentage of your food is home-cooked? ______ Who cooks? ________________
Where does the rest come from? _____________________________________________
Do you crave sugar, coffee, caffeine, cigarettes, or have any other addictions?
________________________________________________________________________
Anything else you would like to share?
________________________________________________________________________
________________________________________________________________________
Women Only:
Are you periods regular? ____ How many days is your flow? ____ How frequent? ____
Painful or symptomatic? Please explain: ______________________________________
Reached or approaching menopause? _________________________________________
Birth Control History: _____________________________________________________
Do you experience yeast infections or urinary tract infections? Please explain:
________________________________________________________________________
Symptom Survey
________________________________________________________________________
For Health Counselor’s Use Only
Blood Pressure Sitting _____/_____
Blood Pressure Standing_____/_____
Heart Rate _______ BPM
________________________________________________________________________
Please fill out the form below. If the symptom does not apply to you, you do not have to fill out
anything for that symptom. If it does apply to you, please put “1” for mild (occurs rarely), “2” for
moderate (occurs several times a month), and “3” for severe (occurs almost constantly). Some
symptoms may repeat among groups, but it is important to complete the entire form.
GROUP 1
Acid foods upset __
Get chilled often __
Lump in throat __
Dry mouth, eyes, or nose __
Pulse speeds after meals __
Failure to calm down __
Cuts heal slowly __
Gag easily __
Startles easily __
Extremities cold and/or clammy __
Strong light irritates __
Urine amount reduced __
Heart pounds after retiring __
Nervous stomach __
Appetite reduced __
Cold sweats __
Fever easily __
Neuralgia (nerve pain) __
Blinks little, stares often __
Sour stomach __
GROUP 2
Joint stiffness upon rising __
Muscle, leg, toes cramps at night __
Butterfly stomach __
Eyes and/or nose watery __
Eyes blink often __
Eyelids puffy __
Indigestion soon after meals __
Always hungry __
Digestion rapid __
Vomiting frequent __
Hoarseness frequent __
Breathing irregular __
Pulse slow __
Gagging reflex slow __
Difficulty swallowing __
Constipation/diarrhea alternating __
“Slow starter” __
Get chilled frequently __
Perspire easily __
Circulation poor __
Subject to colds, asthma, bronchitis __
GROUP 3
Eat when nervous __
Excessive appetite __
Hungry between meals __
Get shaky if hungry __
Fatigue, eating relieves __
Lightheaded if meals delayed __
Heart palpitates if meals delayed __
Afternoon headaches __
Overeating sweets causes illness __
Awaken after few hours of sleep __
Crave candy, coffee, soda in afternoon __
Moods of depression __
Abnormal cravings for sweets or snacks __
GROUP 4
Hands and feet go to sleep easily __
Sigh frequently __
Aware of breathing heavily __
High altitude discomfort __
Susceptible to colds and fevers __
Afternoon yawner __
Get drowsy often __
Swollen ankles __
Charley horses __
Shortness of breath upon exertion __
Dull pain in chest radiating to left arm __
Bruise easily __
Tendency to anemia __
Nose bleeds frequent __
Ringing in ears __
Tightness in chest __
GROUP 5A
Dizziness __
Dry skin __
Burning feet __
Blurred vision __
Itching skin and feet __
Excessive hair loss __
Frequent skin rashes __
Bitter, metallic taste in mouth __
Bowel movements painful or difficult __
Worrier __
Headache over eyes __
GROUP 5B
Greasy foods upset __
Stools light colored __
Skin peels on foot soles __
Pain between shoulder blades __
Use laxatives __
Stools alternate from soft to watery __
History of gallbladder issues __
GROUP 5C
Sneezing attacks __
Nightmares __
Bad breath __
Milk products cause distress __
Sensitive to hot weather __
Burning or itching anus __
Crave sweets __
GROUP 6A
Loss of taste for meat __
Lower bowel gas several hours after eating __
Burning stomach sensations, eating relieves __
GROUP 6B
Coated tongue__
Pass large amounts of foul-smelling gas __
Indigestion ½-1 hours after eating __
GROUP 6C
Irritable bowel __
Gas shortly after eating __
Stomach bloating after eating __
GROUP 7A
Insomnia __
Nervousness __
Can’t gain weight __
Intolerance to heat __
Highly emotional __
Flush easily __
Night sweats __
Thin, moist skin __
Inward trembling __
Heart palpitations __
Increased appetite without weight gain __
Pulse fast at rest __
Eyelids and/or face twitch __
Irritable and restless __
Can’t work under pressure __
GROUP 7B
Increase in weight __
Decrease in appetite __
Fatigue easily __
Ringing in ears __
Sleepy during day __
Sensitive to cold __
Dry or scaly skin __
Constipation __
Mental sluggishness __
Hair coarse __
Headaches upon rising __
Slow pulse (below 65) __
Frequent urination __
Impaired hearing __
Reduced initiative __
GROUP 7C
Failing memory __
Low blood pressure __
Increased sex drive __
Headaches __
Decreased sugar tolerance __
GROUP 7D
Abnormal thirst __
Bloating of abdomen __
Weight gain around hips or waist __
Sex drive reduced __
Tendency to ulcers and/or colitis __
Increased sugar tolerance __
Women: Menstrual irregularity __
GROUP 7E
Dizziness __
Headaches __
Hot flashes __
Increased blood pressure __
Hair growth on face of body (female) __
Sugar in urine without diabetes __
GROUP 7F
Weakness __
Chronic fatigue __
Low blood pressure __
Nails weak ridged __
Tendency to hives __
Arthritic tendencies __
Perspiration increased __
Bowel disorders __
Poor circulation __
Swollen ankles __
Crave salt __
Brown spots or bronzing on skin __
Allergies __
Tendency to asthma __
Respiratory disorders __
GROUP 8
Apprehension __
Irritability __
Morbid fears __
Never seems to get well __
Forgetfulness __
Indigestion __
Poor appetite __
Craving for sweets __
Muscular soreness __
Depression __
Noise sensitivity __
Acoustic hallucinations __
Tendency to cry for no reason __
Skin sensitive to touch __
Anorexia __
Bulimia __
Inability to concentrate __
Frequent stuffy nose __
Loose joints __
Acne __
Urination difficult, dribbling __
Night urination __
Feeling of incomplete bowel evacuation __
Leg nervousness __
Taunya Bruton, H.C., BSc.
Certified Health Counselor
Phone: 540-381-6215
Fax: 540-381-6216
taunya@lifeinbalancecenter.com
www.truewealthishealth.com
www.lifeinbalancecenter.com