Health History

Medical information
Do you have any allergies or sensitivites?
- Yes
- No
Please detail
Do you take any vitamins, supplements or medications?
- Yes
- No
Please list
What role does exercise play in your life?
Please explain anything you have done in the past, what you have liked or disliked. If you are currently training, please list any relevant details such as average running splits, 1 rep maxes in the gym, limitations on certain movements etc.

Food information
What is your food like these days?
Describe an average day
Breakfast Lunch Dinner Snacks Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
- Yes
- No
Do you cook?
- Yes
- No
What percentage of your food is home cooked?
Please enter a number from 0 to 100.
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, alcohol or have any major addictions?
- Yes
- No
Please list what you usually crave
The most important thing I should change about my diet to improve my health is
Anything else you would like to share?
Section Break
Name
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Personal details

Breakfast	Lunch	Dinner	Snacks	Liquids