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The Wild Movement
Health History 2020
Please take your time to fill out this form, it should take about 10 minutes and helps us to better cater to your needs. All information remains strictly confidential.
Step 1 of 6 - Personal details
How often do you check your email?
Once per day
Every few days
Once per week
Date of birth
Date Format: DD dash MM dash YYYY
Place of birth
Skinfolds or Body fat %
Weight 6 months ago
Weight 1 year ago
Would you like your weight or body composition to be different? If so, how?
Hours of work per week
Please state your main health or fitness concerns
Any other concerns or goals?
At what point in your life did you feel your best?
Any serious illnesses or injuries in your life?
How is/was the health of your mother?
How is/was the health of your father?
When do you have the most energy throughout your whole day?
Any regular pain, stiffness, or swelling?
When and where?
How would you rate your libido?
Are your bowel movements:
Regular (roughly same time each day)
Irregular (can’t pick them)
Any constipation, diarrhea or gas?
Has your Dr ever told you you have high or Low Pressure?
How would you say your ability to cope with stress is?
How would you say your ability to concentrate is?
Would you say you generally feel:
Do you have trouble falling asleep at night?
Do you have difficulty waking in the morning?
Do you sleep less than 8-9 hours per night?
Do you wake up once or more during the night?
Do you sleep in a room with any light or noise?
Do you wake up tired?
Do you need an alarm to wake up?
Do you go to bed later than 11pm and get up earlier than 6am?
Do you use medications – over the counter or prescriptions to sleep?
Do you have any allergies or sensitivites?
Do you take any vitamins, supplements or medications?
What role does exercise play in your life?
Please explain anything you have done in the past, what you have liked or disliked. If you are currently training, please list any relevant details such as average running splits, 1 rep maxes in the gym, limitations on certain movements etc.
What foods did you eat often as a child?
Recall as best as you can
What is your food like these days?
Describe an average day
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?
What percentage of your food is home cooked?
Please enter a number from
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, alcohol or have any major addictions?
Please list what you usually crave
The most important thing I should change about my diet to improve my health is
Anything else you would like to share?
This field is for validation purposes and should be left unchanged.