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?
Phone
This field is for validation purposes and should be left unchanged.

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