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HEALTH HISTORY FORM

All of your information will remain confidential between you and the Health Coach.
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- Step 1 of 4

Personal Information

Name *

First

Last

Email *

How often do you check email?

Home Phone

Work Phone

Mobile Phone

Age

Height

Birthdate

Place of Birth

Current Weight

Weight Six Month Ago

Weight One Year Ago

Would you like your weight to be different? If so, please explain:

Social Information

Relationship Status

Where do you currently live?

Children

Pets

Occupation

Hours of work per week

Health

Please list your main health concerns

Other concerns and/or goals?

At what point in your life did you feel 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? If so, please explain:

Any pain, stiffness or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain:

Are your periods regular?

How many days is your flow?

How frequent?

Painful or symptomatic? Please explain:

Reached or approaching menopause? Please explain:

Birth control history:

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

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 do sports and exercise play in your life?

Food Information

What foods did you eat often as a child?

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 from?

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

The most important thing I should do to improve my health is:

What is your diet like these days?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids

Additional Comments

Anything else you would like to share?:

Captcha *

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ABOUT ME
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MEMBERS
TESTIMONIALS
CONTACT

E: yesyoucan.58@yahoo.com

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