NUTRITION HEALTH HISTORY
   
TODAY'S DATE MM/DD/YYYY
NAME
ADDRESS 1
ADDRESS 2
CITY, ZIP               
HOME TELEPHONE BEST TIME TO CALL 
OTHER TELEPHONE
EMAIL
DATE OF BIRTH MM/DD/YYYY
AGE  YRS OLD
HEIGHT INCHES
WEIGHT POUNDS

FOOD ALLERGIES

SEASONAL ALLERGIES
PET ALLERGIES
USE TOBACCO HOW MUCH? PGK/DAY
ALCOHOL
CAFFEINE USE
WHAT WOULD YOU WISH TO ACHIEVE FROM THE PRACTICAL HEALTH EDUCATION SESSION:
   
PRESENT ILLNESSES: DIABETES, HYPERTENSION, HEART DISEASE, HIGH CHOLESTEROL, OSTEOPOROSIS ETC
   
PAST ATTEMPTS AT WEIGHT ELIMINATION, (DIETS, MEDICATIONS, SPECIAL PROGRAMS)
   
   
WEEKLY EXERCISE PLAN?
   
WEEKLY FUN PLAN-STRESS RELIEF: