Jeanine Finelli, CHC - Clean up you diet ... for life!

Health History Form Please fill in the information below.  It will give me a better understanding of your wellness habits, and your goals. All information shared with me is entirely confidential.   Name Address City State Zip Code Email How often do you check mail? Home Phone () - Work Phone () - Cell Phone () - Age Height Birthdate Place of Birth Current Weight Weight six months ago One year ago Would you like your weight to be different? If so, what? Relationship status Children? Pets? Occupation Hours of work per week Please list your main health concerns Other concerns and/or goals? Any serious illness/hospitalizations/injuries? How is the health of your mother? How is the health of your father? What is your ancestry? What blood type are you? Do you sleep well? How many hours? Do you wake up at night? Why? Any pain, stiffness, or swelling? Constipation/Diarrhea/Gas? Allergies or sensitivities? Please explain. Are your periods regular? How many days is your flow? How frequent? Painful or symptomatic? Please explain. Reaching or Approaching Menopause? Please explain. Birth control history Vaginal infections, reproductive concerns? Do you take any supplements or medications? Please List Any healers, helpers, pets or therapies with which you are involved? What role do sports and exercise play in your life? What foods did you eat often as a child? (Breakfast) What foods did you eat often as a child? (Lunch) What foods did you eat often as a child? (Dinner) What foods did you eat often as a child? (Snacks) What foods did you eat often as a child? (Liquids) What’s your food like these days? (Breakfast) What’s your food like these days? (Lunch) What’s your food like these days? (Dinner) What’s your food like these days? (Snacks) What’s your food like these days? (Liquids) Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? Do you cook? What percentage of your food is home cooked? What percentage is not? Where do you get the rest from? Do you crave sugar, coffee, cigarettes, or have any major addictions? The most important thing I should change about my diet to improve my health is Anything else you would like to share?   Home | Your Program Options | About Jeanine | Events / Links Monthly News Letter | Health History Form | Contact Me | Give & Get Support Blog ©2009 Love Your Self To Health