Back to Course First Steps to A Healthy You 0% Complete 0/2 Steps HIPPA AGREEMENT Your Health History Participants4 Amanda Rebekah raisingsails Roseann First Steps to A Healthy You Your Health History In Progress Lesson 2 of 2 In Progress ← Previous Your Health History raisingsails December 4, 2020 Step 1 of 3 33% Personal InformationName* First Last Email* Phone*AgeSexMaleFemaleDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Height Feet Inch Place of Birth*Current WeightWeight 6 Months AgoWeight One Year AgoWould You Like Your Weight To Be DifferentYesNoTarget Weight Social InformationRelationship StatusSingleIn A RelationshipMarriedSeperatedDivorcedWidowedIt's ComplicatedNumber of Children012345678+Where do you currently live?List Any Pets You May HaveOccupationHours Worked Per WeekHealth InformationList Your Main Health ConcernsOther Concerns Or Goals?At What Point In Your Life Did You Feel Your Best?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 / Night?Less Than 3456789 or MoreAny Serious Illnesses/Hospitalizations/Injuries?YesNoIf So What?Do You Wake Up At Night?YesNoWhy?Any Pain, Stiffness, or Swelling? If So Where?Constipation/Diarrhea/Gas?Allergies or Sensitivities? Please Explain: Women's HealthAre Your Periods Regular?YesNoNot SureHow Many Days Is Your Flow?123456+Painful or Symptomatic? If So Pleas Explain:Reached or Approaching Menopause? Please Explain:Birth Control HistoryDo You Experience Yeast Infections or Urinary Tract Infections? Please Explain:Men's HealthAre Your Moods Regular? Explain:Do You Have Mood Swings? If So, How Frequently?Do You Have Difficulty Achieving Erection? If So, Explain:Do You Experience Difficult Urination or Urinary Tract Infections? If So, Explain:Have You Reached or Approaching Andropause? If So, Explain:Medical InformationList Any Supplements or MedicationsClick the + for additional rows. Any Healers, Helpers, or Therapies In Which You Are Involved?Click the + for additional rows. What Role Does Sports & Exercise Play In Your Life?Food InformationWhat Food Did You Eat Often As A ChildClick the + for additional rows.BreakfastLunchDinnerSnacksLiquids What Is Your Diet Like These Days?Click the + for additional rows.BreakfastLunchDinnerSnacksLiquids Will Family and/or Friends Be Supportive of Your Desire To Make Food and/or Lifestyle Changes?YesNoNot SureWhat Percentage of Your Food Is Home-Cooked?25% or Less50%75% or MoreAll of My FoodWhere Do You Get The Rest From?Do You Crave Sugar, Coffee, Cigarettes, or Have Any Major Addictions? If So, Explain:The Most Important Thing I Should Change About My Diet To Improve My Health Is:Anything Else You Would Like To Share?Login InformationOnce onboarded, you'll be able to log into your account to access all your information, track progress & access exclusive resources!Password* Enter Password Confirm Password Strength indicator CAPTCHA