Health History Form - Tali's Yoga

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Name* This field is required.
First Name
Last Name
2
Mobile Phone Number
Area Code
Phone Number
3
Email* This field is required.
example@example.com
4
How often do you check your email?
5
Where do you currently live?* This field is required.What time zone is that?
6
Height (please indicate if ft or cm):* This field is required.
7
Age:* This field is required.
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Date of birth:* This field is required.
Date
Year
Month
Day
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Place of birth (country) :* This field is required.
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Current weight (pounds or kg):* This field is required.
11
Weight six months ago:* This field is required.
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Weight one year ago:* This field is required.
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Would you like your weight to be different?* This field is required.
YESNO
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If so, what?
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Relationship status:* This field is required.
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Children:* This field is required.
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Pets:* This field is required.
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Occupation:* This field is required.
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Hours of work per week:* This field is required.
20
What food did you eat often as a child?* This field is required.
Breakfast
Lunch
Dinner
Snacks
Liquids
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Is there anything else you would like to add?
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What is your food like these days?* This field is required.
Lunch
Dinner
Snacks
Liquids
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Is there anything else you would like to add about your eating habits?
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Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?* This field is required.
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What is the most important thing you should change about your diet to improve your health? * This field is required.
26
Please list your main health concerns:* This field is required.We will go more in depth during our Health History Consultation
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Did you underwent any serious illnesses/hospitalisation/injuries?* This field is required.Please specify
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Are you taking any medications or supplements?* This field is required.Please specify
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What role do sports and exercise play in your life?* This field is required.
30
Are you involved with any healers, helpers, or therapies? * This field is required.
31
Do you struggle with any of those: heartburn, constipation, diarrhoea, gas IBS, indigestion?* This field is required.Or anything else happening with your digestive health?
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Do you experince any pain, stiffness, or swelling? * This field is required.
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Do you have any allergies or food sensitivities? * This field is required.
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What is your blood type?* This field is required.If you know it.
35
What is your ancestory?* This field is required.Where does your parents and their parents come from?
36
What is/was your mother health?* This field is required.
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What is/was your father health?* This field is required.
38
Is there anything else you would like to share?
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Are your periods regular?
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How many days is your flow?
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How frequent? Is it every 28 days? Or more or less?
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Are your periods painful or symptomatic? If so, please explain
43
Have you reached or are you approaching menopause? If so, please explain:
44
What is your birth control history?
45
Do you experience yeast infections or urinary tract infections? If so, please explain:
46
What is the one urgent issue you want to have addressed the most at this point?
47
Would you like to receive further Newsletter from me in the future?* This field is required.Arleta Blackley-Wiertelak
YESNO
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