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Health Form

All of your information will remain confidential between you and the Health Coach.

Health History
First Name
Last Name
Email address
How often do you check email?
Home Phone
Work phone
Cell phone
Age
Height
Birthdate
Place of birth
Current weight
Weight 6 months ago?
One year ago?
Would you like your weight to be different? If so, what?
Relationship status
Where do you currently live?
Children
Pets
Occupation
Hours of work per week
Please list your main health concerns
Any pain, stiffness or swelling?
Any other concern and/or goals?
Constipation/Diarrhea/Gas?
At what point in your life did you feel best?
Allergies or sensitivities? Please explain.
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?
Reached or approaching menopause? Please explain.
How is your sleep?
Birth control history
How many hours?
Do you experience yeast infections or urinary tract infections? Please explain.
Do you wake up at night? Why?
Do you take any supplements or medications? Please list.
Any healers, helpers or therapies with which you are involved? Please list.
What role do sports and exercise play in your life?
Breakfast
Lunch
Dinner
Snacks and Liquids
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?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is –
Anything else you would like to share?
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