General Health History - Cambiati Wellness & Weight Loss | Contra Costa: Lafayette, Walnut Creek Alamo CA

Name*
First Last
Date*
MM slash DD slash YYYY
Age*
Height*
Weight (in pounds)*
Occupation*
Hours of Work Per Week*
Preferred Method of Communication (choose all that apply):*
- Email (remember to pull Cambiati Wellness out of your spam folder)
- Text
- Phone
Living Situation (Family, couple, children,single, pets)*
Living Situation (Family, couple, children,single, pets)*
Who do you cook for? Please note if you cook a separate meal for yourself and another for others.*
What percentage of food is home cooked?*
Is there anything else that you would like to share about cooking? For example you enjoy cooking but lack time or you don't enjoy cooking.
Please describe medical conditions you are facing or have been challenged with in the past (including hospitalizations). If none type that in the box.*

Do you take any of the following (check all that apply):*
- Prescription Medications
- Over the Counter Medications
- Vitamins and/or Herbs
- None of the above
List all prescription medications with dosages and frequency. If it is easier you can send in photos to info@cambiati.com and note "see photos" in this box.*
List all over the counter medications with dosages and frequency.*
List all vitamins and herbs with dosages and frequency. If it is easier you can send in photos to info@cambiati.com and note "see photos" in this box.*
List all cannabis products with dosages and frequency.*
Do you have any medical implants? i.e. dental, knee replacement, hip replacement, pacemaker, etc.*
What is your ancestry? (If unknown please note that.)*
What is your blood type?*
On a scale of 1-10 what is your stress level on an average day to day basis?*
Please enter a number from 1 to 10.
What are the major causes of stress in your day?*
On average, how many hours per night do you typically sleep?*
Please enter a number from 1 to 16.
What time do you go to bed?*
How is your sleep quality? (Choose all that apply)*
- I sleep like a baby & do not have trouble sleeping
- I have trouble going to sleep
- I wake up in the middle of the night once
- I wake up multiple times in the middle of the night
If you wake up in the middle of the night, what time do you usually wake?*
Do you feel rested upon waking?*
Do you anything to help you sleep (melatonin, prescription medication, nyquil, etc.)*
Please describe anything to help you sleep (melatonin, prescription medication, nyquil, etc.)*
Do you have IBS, heartburn, cramps, diarrhea or other digestion issues?*

What do you do (or have you tried) as a remedy for IBS, heartburn, cramps, diarrhea or other digestion issues?*
If weight loss is a goal, what is your biggest challenge?
Do you have any food or substance cravings (ice cream, caffeine, cigarettes, alcohol, drugs)?*
When do you typically have cravings (place, time of day)?
Do you rely on caffeine to get you going in the morning or through your day?*
What are your caffeinated beverages of choice?*
Do you smoke?*
How much do you smoke? Please differentiate between marijuana and cigarettes.*
Do you drink alcohol?*
Please list the Number of drinks per day & per week. Also note what type of alcohol you are drinking.*

What role does sports/exercise/movement play in your life and in what forms do you participate? Please include the number of hours per week.*
Please list any known food allergies. (Type none if you have no allergies.)*
Please list any known food sensitivities (Any foods that make you feel bad):
What foods do you dislike?
Is there anything else that you would like to share?

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