HEALTH HISTORY

Please fill out the form completely. Your information will remain confidential between you and your Health Coach

Health History

Personal
Name*
First Last
Phone*
Email*
Age
Height
Date of Birth
MM slash DD slash YYYY
Place of Birth
How often do you check your email?
Current Weight
Weight Six Months Ago
Weight One Year Ago
Would you like your weight to be different?
- Yes
- No
If so, how?
Social
Relationship Status:
Where do you live?
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Any children?
Any pets?
Occupation
How many hours do you work per week?
General Health
What are your main health concerns?
Any other concerns and/or goals?
At what point in your life did you feel your best?
Any current or previous serious illnesses, hospitalizations, or injuries?
How is/was your mother’s health?
How is/was your father’s health?
How is your sleep?
How many hours do you sleep per night?
Do you wake up during the night? If so, why?
Any pain, stiffness, or swelling?
Any constipation, diarrhea, or gas?
Any allergies or sensitivities?
Medical
List all supplements or medications
Are you involved with any healers, helpers, or therapies?
What role do sports and exercise play in your life?
Food
Will your family and friends be supportive of your desire to make food and/or lifestyle changes?
- Yes
- No
Do you cook?
- Yes
- No
What percentage of your food is home-cooked?
Where does your non-home-cooked food come from?
What foods did you eat often as a child?
Breakfast

if there is more than one answer, separate them with commas
Lunch

if there is more than one answer, separate them with commas
Dinner

if there is more than one answer, separate them with commas
Snacks

if there is more than one answer, separate them with commas
Liquids

if there is more than one answer, separate them with commas
What foods do you typically eat these days?
Breakfast

if there is more than one answer, separate them with commas
Lunch

if there is more than one answer, separate them with commas
Dinner

if there is more than one answer, separate them with commas
Snacks

if there is more than one answer, separate them with commas
Liquids

if there is more than one answer, separate them with commas
Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?
What is the most important thing you should change about your diet to improve your health?
Additional Comments
Is there anything else you would like to share?

HEALTH HISTORY

Health History

Personal

Social

General Health

Medical

Food

Additional Comments