Health History Form

Please fill out the following form in order to participate in Health Coaching. All information will remain confidential.

Personal Information

First Name

Last Name

How often do you check email?

Phone

Age

Height

Birthday

Current Weight

Weight 6 Months Ago

Weight 1 Year Ago

Would you like your weight to be different? If so what?

Social Information

Relationship status

Where do you currently live?

Children? Pets?

Occupation

Hours of work per week

Health Information

Please list your main health concerns

Other concerns and/or goals?

At what point in your life did you feel better?

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 is your blood type?

How is your sleep? How many hours a n ight? Do you wake up at night?

Why?

Any stiffness? Pain? Swelling?

Constipation/ diarrhea/ gas?

Allergies or sensitivities? Please explain

Womens Health

Are your periods regular?

How many days is your flow

Painful or symptomatic?

Reached or approaching menopause

Birth control history

Do you experience yeast infections or urinary tract infections? Please explain

Diet & exercise

Do you take any supplements or medications?

What role do sports and exercise play in your life? How frequent?

What was your diet like as a child?

What is your food like these days? Breakfast/ lunch/ dinner/ snacks/ 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 of our food?

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

Do you drink? If so, how many drinks per week?

Do you smoke marijuana? If so, how many times per week?

What is the most important thing you should do to improve your health?

Anything else you would like to share?

Thanks for submitting!