Client Health History Form (Confidential) Please complete each section to the best of your knowledge. Step 1 of 34 - Contact Details 0% Personal DetailsName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Marital StatusSingleMarriedDivorcedPhoneEmail Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth (D.O.B) DD slash MM slash YYYY Your AgePlease enter a number from 18 to 80.Your Weight (kg)Please enter a number from 40 to 200.Your Height (cm)Please enter a number from 100 to 300.Occupation Do you work night shifts? Yes No Other General Practitioner (GP) / Doctor GP PhoneGP Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PermissionDo I have permission to contact your Doctor if it becomes necessary to do so? Yes No Health History (Part 1)NUTRITIONWhat current health concerns do you have and when did the problem start? When did the problem start? Current and / or historically significant illness? Any injuries, serious accidents or surgeries? Do you take any supplements? Any food allergies and sensitivities? Any environmental allergies? What are your current Wellness Goals?(i.e. Nutrition, Diet, Cooking, Lifestyle - such as: Physical activities, Stress reduction, Sleep, Rest, Love, Social connection & Relationships, Avoid / Minimise harmful substances Overall health and wellbeing?What would you like to work on with your health coach? How do you see your future health?(in 2, 3 and 6 months) How would you feel if you achieved these results? What have you done in the past regarding your conditions, what worked and what didn't? What obstacles, challenges, or struggles prevent you from achieving these results? Food and Drink Habits Please provide 3 days of examples of your current food and drink habitsBreakfast - Day 1 Breakfast - Day 2 Breakfast - Day 3 Lunch - Day 1 Lunch - Day 2 Lunch - Day 3 Desserts / Sweets / Chocolate - Day 1 Desserts / Sweets / Chocolate - Day 2 Desserts / Sweets / Chocolate - Day 3 Drinks - Soft drink & Carbonated drinks - Day 1 Drinks - Soft drink & Carbonated drinks - Day 2 Drinks - Soft drink & Carbonated drinks - Day 3 Hot beverage - Day 1 Hot beverage - Day 2 Hot beverage - Day 3 How much water do you drink in a day? Do you have sweet food cravings?Please give examples Do you have savoury food cravings?Please give examples Do you experience compulsive, emotional or binge eating?Please give examples Do you overeat on a daily basis?Please give examples How is your food appetite?Please give examples Childhood Food and Drink Habits Please provide 1 day examplesBreakfastPlease give examples LunchPlease give examples DinnerPlease give examples DrinksPlease give examples SnacksPlease give examples OtherPlease give examples Lifestyle Medicine Six Principles QuestionnaireDo you have specific dietary guidelines?(e.g. Eating standard diet, animal products included, Vegetarian, Vegan, Other What foods do you dislike and are not willing to include in your diet?Please give examples What foods and drink would be hardest to give up?Please give examples How often do you eat out each week and what is your usual choice?Please give examples How often do you have take aways and what is your usual choice?Please give examples How often do you cook at home, from scratch, using whole foods?Please give examples Do you consume natural whole foods?Please give examples (i.e. Fruit, Vegetables, Nuts & Seeds, Whole Grains, Legumes). How much and how often? Regular Physical Activity QuestionnaireDo you currently exercise or are physically active?Please give examples What type of exercise or sport do you do?Please give examples How many times per week?Please give examples How long are the sessions?Please give examples How often, per week, do you spend time in Nature?Please give examples (i.e. Park, Woods or Forest, Beach) Stress Reduction QuestionnaireOn a daily basis, how do you reduce your stress?Please give examples (i.e. Listen to music, go for a walk) How would you rate your daily stress levels?0 = Low Stress, 6 = Highly Stressed 0 1 2 3 4 5 6 Sleep and Rest QuestionnaireHow is your overall quality of sleep?Please give examples What time do you normally go to bed?Please give examples How many hours do you usually sleep?Please enter a number from 1 to 10.Do you feel refreshed in the morning?Please give examples Relaxation QuestionnaireWhat do you do for relaxation?How often do you find time to relax and focus on your self each week? Never Once a week Once a day Hourly All the time Love QuestionnaireDo you practice self-love / self-care? Yes No Do you practice love and intimacy? Yes No Do you practice spirituality? Yes No Social Connection QuestionnaireDo you regularly socialise?Please give examples (Friends, Family, Spouse, Social Groups, Community?) and how often Do you have an interest or hobby that brings you true happiness and joy?Please give examples and how often. Do you have a life purpose or goals? Yes No Avoid / Minimise Harmful Substances QuestionnaireDo you smoke? Yes No How many Cigarettes / Cigars / Other to you currently smoke each day?Please give examples Do you drink alcohol? Yes No How many days per week / how many units?Please give examples Do you use recreational drugs? Yes No Body Function QuestionnaireDo you experience any current symptoms or concerns? Gut Health Digestion Metabolism Select AllDo you experience any of the following? Frequent Colds Infections Cold Sores Select AllDo you experience any of the following? Headaches Hard to concentrate Cannot think clearly Stressed Anxiety Select AllDo you experience any of the following? Low mobility Painful Joints Inflammation Arthritis Back Pain Gout Select All Female Reproductive Health Questionnaire(If applicable)Period? Yes No Painful Periods? Yes No Menopause? Yes No Libido? Low Normal Fertility Problems? Low Normal Male Reproductive Health Questionnaire(If applicable)Erectile problems? Yes No Fertility problems? Yes No Sex drive? Low Normal Health Questionnaire40 Plus - Do you have any age related health concerns or goals?Please give examples How are your energy levels and vitality in the morning and at the end of the day?Please give examples Do you currently suffer with the following? Illness Pain Inflammation Would you like help with the following? Weight Loss Weight Gain Additional Comments for your Health CoachOn submission of this Health History form, details will be sent to your Health Coach to review and discuss with you further at you appointment. You will be directed to our consent form to esign your agreement to work with Longevity Six.PhoneThis field is for validation purposes and should be left unchanged.
