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Physical Health History Form Template

As a health and wellness professional, you understand the importance of gathering a full physical health history from your clients. This Physical Health History Form Template can help you do just that. This form is designed to help you collect the information necessary for you to provide the best possible care.

This form gives you an opportunity to record a comprehensive health history from your client. It covers topics such as past medical conditions, surgeries, allergies, family history, medications, and lifestyle habits. There are also questions covering diet, nutrition, and mental health.

The Physical Health History Form Template includes space for your client to provide any additional information they feel is important to make sure you have a full view of their health as you're developing a plan of action.

Physical Health History Form Template

  1. On a scale of 1-5, 1 being Barely Alive and 5 being Totally Fit, what is your current fitness level?

  2. What will change for you emotionally, physically and spiritually when you reach a 5?

  3. What percentage of your body's natural healing powers are you currently using?

  4. Has your doctor ever told you that you need to lose/gain weight? If so, please explain.

  5. Current Weight/Size

  6. Ideal Weight/Size

  7. How many hours of sleep do you get per night?

  8. On a scale of 1-5, 1 being Barely Sleeping and 5 being Best Sleep Ever, how would you rate your sleep?

  9. If you wake up frequently during the night, why do you believe that is?

  10. Do you experience pain, swelling, or stiffness? If so, which areas of your body?

  11. Please select all that apply to your current or past health state:

  12. Please list any medications you are currently on or have been on in the past.

  13. Do you smoke cigarettes?

  14. Do you drink alcohol?

  15. Are you consuming any recreational drugs? If so, please list types and frequency.

  16. What is your ancestry? (The region your ancestors are from)

  17. Are you currently, or have you ever been, under the care of a natural healer, energy therapist, or other helper in the alternative/holistic field? If so, please describe.

  18. Are you currently under the care of a physician, chiropractor, or other health care professional?

  19. If so, have you consulted him/her regarding your desire to begin a new program?

  20. If you would like us to connect with them regarding any specific recommendations during our coaching together, please list their name and contact info.

  21. Please list any major surgeries you've had.

  22. Please list any current supplements you are taking.

  23. Please list any food allergies/sensitivities you are aware of.

  24. What percentage of your food is home-cooked? What percentage is pre-made/take-out?

  25. How would you consider your current diet?

  26. How was your diet as a child/growing up?

  27. Do you have any specific food cravings such as coffee, sugar, or other items you feel you cannot control yourself with? If so, please list.

  28. Describe your current relationship to food and how it developed/who you learned it from.

  29. Describe a typical day of eating, including number of meals, drinks, snacks, and amount of water consumption.

  30. Please list anything else you feel I need to know about your health.

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