Health History form

All your information will remain confidential between you and the health coach.

PERSONAL INFORMATION
Name*
First Last
Email*
How often do you check e-mail?*
Home/Primary Phone*
Work Phone
Mobile Phone
Age*
Height*
Birthdate*
Place of birth*
Current weight*
Weight six months ago*
One year ago*
Would you like your weight to be different?*
- Yes
- No
- Not sure
What would you like your weight to be?*
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 you best?*
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?*
How is your sleep?*
How many hours?*
Do you wake up at night?*
- Yes
- No
- Occasionally
Why?
Any pain, stiffness or swelling?*
Constipation/Diarrhea/Gas?*
Allergies or sensitivites? Please detail:*
MEDICAL INFORMATION
Do you take any supplements or medications? Please list:*
Any healers, helpers, or therapies with which you are involved? Please list:*
What role does sports and exercise play in your life?*
FOOD INFORMATION
What foods did you eat often is a child?
Breakfast*
Lunch*
Dinner*
Snacks*
Liquids*
What is your food like these days?
Breakfast*
Lunch*
Dinner*
Snacks*
Liquids*
Will your 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 change about my diet to improve my health is?*
ADDITIONAL COMMENTS
Anything else you would like to share?
Comments
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Health History Form

Health History form

All your information will remain confidential between you and the health coach.

PERSONAL INFORMATION

SOCIAL INFORMATION

HEALTH INFORMATION

MEDICAL INFORMATION

FOOD INFORMATION

ADDITIONAL COMMENTS