Health History – Karla’s Kitchen of Nutrition

Karla’s Kitchen of Nutrition

Health History Form

Karla's Kitchen of Nutrition Holistic Wellness and Nutrition Consulting

"*" indicates required fields

Client Information

Full Name*

Date of Birth*

MM slash DD slash YYYY

Phone Number*

Email Address*

Emergency Contact

Name*

Relationship*

Phone Number*

Primary Health Concern

List your top wellness & goals:*

Medical & Health Background

This form is for general wellness purpose only and does not diagnose and treat medical conditions.

Current medical conditions:*

Past surgeries or hospitalizations:*

Family health history:

Are you currently under a physician's care?*

Yes

No

If yes, for what conditions?*

Medications and/or Supplements currently taking:*

Lifestyle & Nutritions

Typical Daily Meals:*

Breakfast

Lunch

Dinner

Snacks

Hydration (average cup per day):*

Caffeine intake:*

Alcohol intake:*

Sleep (average hours per night):*

Physical activity (type & frequency):*

Digestive Health

Appetite:*

Low

Moderate

High

Digestion:*

Comfortable

Occasional discomfort

Frequently discomfort

Bowl movements:*

Regular

Irregular

Constipation

Loose stools

Food sensitive or intolerances:*

Allergies:*

Additional Notes:

Client Acknowledgement

Terms and conditions*

I understand that holistic nutrition consulting provides general wellness guidance and education, its doesn't diagnose, treat, or cure medical conditions. I agree to consult my healthcare provider for medical concerns.

Signature

Date

MM slash DD slash YYYY

Holistic Nutrition Consulting Services