Skip to content
Menu
Home
About
Bio & Qualifications
The Team
Wellness With Me App
Menu Item Separator
Corporate
Consultancy
Bespoke Programmes
Wellness Days
Wellness With Me App
Individual
Contact
Menu
Home
About
Bio & Qualifications
The Team
Wellness With Me App
Menu Item Separator
Corporate
Consultancy
Bespoke Programmes
Wellness Days
Wellness With Me App
Individual
Contact
Senior Health History
HTML
PERSONAL INFORMATION
First Name
*
Last Name
*
Email
*
How often do you check email?
*
Best number to reach you
*
Age
*
Height
*
Date of Birth
*
Place of Birth
*
Current weight
*
Weight six months ago
*
Weight one year ago
*
Would you like your weight to be different?
*
If so, what?
HTML Copy
SOCIAL INFORMATION
Relationship status
*
Where do you currently live?
*
Grandchildren
*
Occupation
*
Hours of work per week
*
What is your retirement plan?
*
HTML Copy Copy
HEALTH INFORMATION
Please list your main health concerns
*
Other concerns and/or goals?
At what point in your life did you feel best?
*
Any serious illnesses/hospitalisations/injuries?
*
How is/was the health of your mother?
*
How is/was the health of your father?
*
What is your ancestry?
*
What blood type are you?
*
How is your sleep?
*
How many hours do you normally sleep?
*
Do you wake up at night?
*
If you answered yes above, why do you wake up at night (if known)?
Any pain, stiffness, or swelling?
*
Constipation/Diarrhea/Gas?
*
Allergies or sensitivities? Please explain:
*
HTML
MEDICAL INFORMATION
Do you take any supplements or medications? Please list:
*
Any healers, helpers, or therapies with which you are involved? Please list:
*
What role do sports and exercise play in your life?
*
What is your energy like?
*
Do you still feel independent? Please explain:
*
Are you part of a community? Please explain:
*
HTML Copy
FOOD INFORMATION
HTML
What foods did you eat as a child?
Breakfast
*
Lunch
*
Dinner
*
Snacks
*
Liquids
*
HTML Copy
What is your food like these days?
Breakfast
*
Lunch
*
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:
*
Additional Comments
Privacy
*
By using this form you agree to the storage and handling of your data by Wellness With Me.
If you are a human seeing this field, please leave it empty.