Jill Mulholland
Holistic Nutrition & Wellness Counselor
Contact Jill Today! 1-917-701-7546

Health History Form
Please fill out the form as thoroughly as possible,
in order to help me understand your needs.

Personal Information

Name:
Address:
E-mail:
I check e-mail:
Home Phone:
Work Phone:
Cell Phone:
Age:
Height:
Birthdate:
Place of Birth:
Current Weight:
Weight 6 months ago:
Weight 1 year ago:
What is your weight goal?

Social Information

Relationship status:
Do you have children?:
Occupation:
Hours of work per week:

Health Information

Please list your main
health concerns:
Any other concerns?
Any serious illness/
hospitalizations/injuries?
How is the health
of your mother?
How is the health
of your father?
What is your ancestry?
Blood Type:
Do you sleep well?
How many hours?
Do you wake up at night?
Why?
Any pain, stiffness
or swelling?
Constipation/Diarrhea/Gas?

WOMEN ONLY:

Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic?
Please explain:
Birth control history:
Vaginal infections,
reproductive concerns?

Food Information

What kind of foods did you eat as a child? What's your food like these days?


Breakfast:
Lunch:
Dinner:
Liquids:
Snacks:
Breakfast:
Lunch:
Dinner:
Liquids:
Snacks:

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?:

Additional Comments

Anything else you
would like to share?

Hera Wellness: For a Lifetime of Balance