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Health History Form
Health History Form
n8wyd
2020-06-02T21:20:31+00:00
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?
Email
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