Personal Health History
Details
Frequent colds/flu/coughs/runny nose/stuffy
Problems sleeping/insomnia
Heart disorder/heart attack/stroke/angina
Osteoporosis/Low bone density
Hypoglycemia (low blood sugar)
Depression/anxiety/psychiatric care
Frequent headaches/migraines
Currently pregnant/breastfeeding
Anorexia/bulimia/binge eating
Joint/back/tendon/muscular pain or injury
Lifestyle Factors
Comments
Do you take time to relax each day?
How is your energy throughout the day?
What is your mood like most days?
Do you experience any cravings throughout the day?
Are you exposed to 2nd hand smoke?
Do you use medicinal or recreational cannabis?
Medications
Please list the name and dosage of any medications you are currently taking as well as the reason for taking it.
Name of Medication
Dosage & Reason For Taking
Vitamins, Minerals, Supplements & Herbs
Please list the name and dosage of any supplements you are currently taking as well as the reason for taking it.
Name Of Supplement
Dosage & Reason For Taking
Family Medical History
List the family member and details
Food/Environmental allergies
Heart disorder/heart attack/stroke
Diabetes/High blood sugar
Hypoglycemia (low blood sugar)
I understand and acknowledge that the nutrition services provided by The Kettlebell Club are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. If you are currently taking any pharmaceutical prescription drugs, it is advised that you consult your Doctor before combining them with nutritional supplements.
