Congratulations!

Your Shake It Off journey has officially begun.

Fill out the appropriate Health History Form as accurately as possible. Nicole will be in touch shortly after you have submitted the required information.

Shake It Off - Women's Health History Form

Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How often do you check email?

Work Phone

(###)

###

####

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Age

Date of Birth

YYYY

Place of Birth

Height

Current Weight

Weight Six Months Ago

Weight One Year Ago

Would you like your weight to be different? If yes, in what way?

Relationship Status

Children

Pets

Occupation

Hours of Work per Week

Please list your primary health concerns.

Please describe any other concerns or goals.

At what point in your life did you feel best?

Have you had 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 blood type are you?

Do you sleep well?

How many hours of sleep do you normally get?

Do you often wake up at night?

If so, why?

Any pains / stiffness / swelling?

Are your periods regular?

How many days is your flow?

How frequent?

Painful or symptomatic? Please explain.

Reached or approaching menopause? Please explain.

Birth Control History

Do you experience yeast infections or urinary tract infections? Please explain.

Do you experience constipation / diarrhea / gas? Please explain.

Do you have any allergies or sensitivities? Please explain.

Do you take any supplements or medications? Please list.

Are there any healers / helpers / therapies with which you are involved? Please describe.

What role does sports and exercise play in your life?

What foods did you eat as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

What's your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

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

What percentage of your food is home-cooked?

Do you cook?

Where do you get the rest from?

Do you crave sugar, coffee, cigarettes / do you have any major addictions?

The most important thing I should change about my diet to improve my health is:

Is there anything else you would like to share?

Shake It Off - Men's Health History Form

Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How often do you check email?

Work Phone

(###)

###

####

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Age

Date of Birth

YYYY

Place of Birth

Height

Current Weight

Weight Six Months Ago

Weight One Year Ago

Would you like your weight to be different?

If so, what do you want to change?

Relationship Status

Where do you currently live?

Children

Pets

Occupation

Hours of Work per Week

Please list your main health concerns.

Do you have any other concerns and/or goals for your health?

At what point in your life did you feel best?

Have you had any serious illnesses / hospitalizations / injuries? Please describe.

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?

Do you wake up at night? If yes, why?

Please describe any pain, stiffness, or swelling you experience.

Do you experience constipation, diarrhea, or gas? Please explain.

Do you have any allergies or sensitivities? Please explain.

Do you take any supplements or medications? Please explain.

Please describe any healers, helpers, or therapies with which you are involved.

What role do sports and exercise play in your life?

What foods did you eat often as a child?

Breakfast

Lunch

Dinner

Snacks

Liquids

What is your food like these days?

Breakfast

Lunch

Dinner

Snacks

Liquids

Will family and/or friends be supportive of your desire to make foods and/or lifestyle changes?

Do you cook?

What percentage of your food is home-cooked?

Where do you get the rest from?

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

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

Is there anything else you would like to share?