Varad Health History Form | Varad Integrative Psychiatry Clinic For Mental Health And Holistic Wellness Center Bellevue

Confidential Health History Form - Male

What are your main health concerns? Any other concerns?

Describe your past health history

Describe your family health history

At what point of your life did you feel the best (motivated, satisfied and accomplished)?

Have you ever practiced any holistic treatments? If yes, please list. Did they help you?

Describe activities that make you feel motivated or happy

What role do sports and exercise play in your life?

Have you observed any mood differences with any foods that you eat? If so, elaborate

What medicines or supplements do you use currently?

Do you have any allergies? If so, please elaborate

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

Have you gained or lost weight recently without intending to?

Do you sleep well? How many hours on average?

How many meals do you take a day?

Describe your food habits these days.

Breakfast Lunch Dinner Snacks Liquids

What percent of your food is home cooked? Where do you get the rest of your food from?

Do you experience constipation or gas?

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