Health History Form

Please Fill Out The Form Below

All of your information will remain confidential between you and the Health Coach.

First Name

Last Name

Home Phone

Work Phone

Cell Phone

Age

Height

Birthday

Place of Birth

Sex

Current Weight

Current Weight Six Months Ago

Current Weight One Year Ago

Would You Like Your Weight To Be Different?

Yes

If Yes, What Is Your Weight Goal?

Relationship Status

Where Do You Currently Live?

Children

Pets

Occupation

Hours Of Work Per Week

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?:

How Is Your Sleep?:

How Many Hours:

Do You Wake Up At Night?:

Why?:

Any Pain, Stiffness or Swelling?:

Constipation/Diarrhea/Gas?:

Allergies Or Sensitivities? Please Explain:

Are your periods regular? (if applicable):

How many days is your flow? (if applicable):

How frequent? (if applicable):

Painful or symptomatic? Please explain (if applicable):

Reached or approaching menopause? Please explain (if applicable):

Birth control history (if applicable):

Do you experience yeast infections or urinary tract infections? Please explain (if applicable):

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?:

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 breakfast foods do you often eat currently?:

What lunch foods do you often eat currently?:

What dinner foods do you often eat currently?:

What snack foods do you often eat currently?:

What liquids do you often drink currently?:

Anything else you would like to share?:

Fatigue

Congestion

Excess Weight

Brain Fog

IBS/Bloating

Constipation

Diarrhea

Reflux

Headaches

Joint Pain

Itchy Skin

Sweet Cravings

Sleeplesness

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Your Signature

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Rate each of the following symptoms using the following point scale:

0 -- Never or almost never have the symptoms

1 -- Occasionally have it, effect is not severe

2 -- Occasionally have it, effect is severe

3 -- Frequently have it, effect is not severe

4 -- Frequently have it, effect is severe