Guardian Angel  Wellness  

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Health History

Please fill out this form to get started. All information is confidential.

First Name: *
Last Name: *
Birthdate:
Age:
Email: *
How often do you check your email?:
Home phone:
Mobile phone:
Height:
Current weight:
Would you like your weight to be different? If so, what?:
Relationship status - Married, Single, Etc.:
Any children?:
Any pets?:
Occupation?:
Hours worked per week?:
Please list your main health concerns:
Other concerns and/or goals?:
At what point in your life did you feel your best?:
Any allergies or sensitivities? Please explain:
How is your sleep?:
Do you take any supplements or medications? Please list:
What role do sports and exercise play in your life?:
What foods did you eat often as a child - for breakfast?:
For lunch:
For dinner:
Snacks:
Liquids:
What is your food like these days - for breakfast?:
For lunch:
For dinner:
Snacks:
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?:
Where do you get the rest from?:
Do you crave sugar, coffee, cigarettes, or have any major addictions?:
The most important thing I should do to improve my health is:
Anything else you would like to share?:
Security Code: *  
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