Health Form

YTC HEALTH FORM

Your Details

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

Email *

Mobile Number *

Number of children and age *

OCCUPATION *

Hours Worked per week *

Are you overwhelmed or frequently stressed out *

Height *

Weight *

If weight is a concern, what is your ideal weight *

Health history

Do you have any injuries, illnesses or conditions? *

Yes No

Chief Health Complaint
(Reason why you are seeking health guidance)

Health goals and concerns you wish to address *

What aggravates or Alleviates the above if anything? *

Current Treatment (medication, psychological, holistic *

Reason why you think you have the current health concerns *

Past serious illness / hospitalisation / injury ? *

What are the symptoms / conditions preventing you from doing in life? *

Daily Nutrition and Lifestyle Routine

Breakfast *

Are you hungry? *

Yes No Sometime

Serving size *

Small Medium Large

Time of Breakfast *

Any further comments *

Lunch *

Are you hungry? *

Yes No Sometime

Serving size *

Small Medium Large

Time of Lunch *

Any further comments *

Dinner *

Are you hungry? *

Yes No Sometime

Serving size *

Small Medium Large

Time of Dinner *

Any further comments *

Snacks *

Are you hungry? *

Yes No Sometimes

Serving size *

Small Medium Large

Time of Snack *

Any further comments *

Beverages per day: Tea/Coffee *

Cravings *

Water intake per day? *

Alcohol per week: Y/N, if yes, how much? *

Smoking? *

Yes No

Recreational drugs? *

Yes No

Sleep Patterns

Please outline your night routine, if you dream and do you wake up at during the night? *

What time do you wake up *

What time do you go to bed? *

Do you feel fresh upon waking? *

Do you fall asleep straight away? *

Bodily functions

Women Only

Exercise, Energy and Resting Patterns

What is your current exercise programme and how many times per week? *

Energy: Please rate current energy levels (1 = little to 10= very high) *

Breathing patterns is short, shallow, long, deep, sigh, yawn or normal *

How do you relax at home? *

Your 6 month vision/objective

What are the 3 most important areas of your health you wish to have resolved or addressed and why? *

If there is anything else you wish to share or comment on? *

Thanking you for your time in completing this Health form. I look forward touching base with you soon.

Vandana

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YTC HEALTH FORM

Your Details

Health history

Chief Health Complaint (Reason why you are seeking health guidance)

Daily Nutrition and Lifestyle Routine

Sleep Patterns

Bodily functions

Women Only

Exercise, Energy and Resting Patterns

Your 6 month vision/objective

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Chief Health Complaint
(Reason why you are seeking health guidance)