Senior Health History Form — Gail's Cupboard

Personal Information

Email Address

How often do you check email?

Height

Weight

Has your weight changed significantly in the past 6 months or year?

Would you like your weight to be different? If so, what?

Social Information

Where do you live?

What is your relationship status?

Do you have grandchildren? If so, how many?

What is your occupation?

How many hours a week do you work?

What is your retirement plan?

Health Information

Please list your main health concerns.

Please list your health goals.

At what age did you feel your best?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

What is your blood type?

How is your sleep?

How many hours do you sleep a night?

Do you wake up in the middle of the night?

Do you feel any pain, stiffness, or swelling? If so, please explain.

Do you experience any constipation, diarrhea, or gas?

Allergies or sensitivities? Please explain.

Medical Information

Do you take any medications or supplements? Please list.

Any healers, helpers, or therapies with which you are involved? Please list.

What role does exercise play in your life?

What is your energy like?

Do you still feel independent? Please explain.

Are you part of a community? Please explain.

Food Information

Are family and/or friends supportive of your desire to make food and lifestyle changes?

What foods did you often eat as a child?

Breakfast / Lunch / Dinner / Snacks / Liquids

What foods do you eat currently?

Breakfast / Lunch / Dinner / Snacks / Liquids

What percentage of your food is home-cooked?

Where do you get the rest?

Do you crave sugar, coffee, cigarettes, or have any other major addictions?

The most important thing I should do to improve my health is...

Additional Information

Anything else you would like to share?