Health History Form Full Name Email Age Height Date of Birth Mobile Phone Current Weight Weight One Year Ago Would you like your weight to be different? If so, how? Relationship Status SingleMarriedDivorced Any children? Ages? Occupation How many hours do you work per week? less than 20more than 20more than 40 What are your main health concerns right now? What have you already tried to resolve this problem? In a scale of 1-10. How important is it for you to solve this issue? [rangeslider Importanceofissue step:1 min:1 max:10 calslider:left sliderstyle:doublelabels slidershow:single rangeshow:enable] Any current or previous serious illnesses, hospitalizations, or injuries? How many hours do you sleep per night? Less than 67 or more Do you wake up during the night? If so, why? Check all that apply to you StiffnessPainSwellingConstipationDiarrheaGasAllergiesSensitivities Briefly describe any other symptoms Are your periods regular? YesNo Are your periods painful or symptomatic? YesNo Have you reached or are you approaching menopause? If so, please explain: Do you experience night sweats? YesNo List all supplements or medications: Are you involved with any healers, helpers, or other therapies? Please explain What role do sports and exercise play in your life? Do you cook? YesNo What percentage of your food is home-cooked? 30% or less60%90% Where does your non-home-cooked food come from? What foods do you typically eat these days for breakfast? What foods do you typically eat these days for lunch? What foods do you typically eat these days for dinner? What foods do you typically eat these days for snacks? What liquids do you often have during the day? Check all that apply to you WaterCoffeeSoft drinksTeaAlcoholic beveragesJuice Do you have any cravings? Check all that applied CoffeeSweetsSalty Any other concerns and/or goals? What are you looking forward to get out of this program? What would success look like for you? Please check this box to acknowledge the following agreement:I am committed to my own personal health and wellness. With this commitment I give my word to: • Be coachable • Be open to new foods, concepts, and exercises • Fulfill on the commitments I make • Eat nourishing foods according to the guidance of my Health Coach • Exercise according to the guidance of my Health Coach • Finding a healthy balance between work and play • Give gratitude in the relationships in my life • Develop a listening to my body’s wants and needs • Powerfully deal with the stressors in my life • Begin and end our sessions on time. You can read full Terms and Conditions Here Sign me up for the newsletter!
