Health History Questionnaire
Please fill out all of the questions as completely as possible prior to our initial call.
Example: New York USA / ET
Phone or Skype if outside US
Family / living situation? (Live alone? Partner? Married? Have kids? How many?)
List your main concerns or goals which have prompted you to seek out health coaching.
Do you experience any of the following?
acne - face
acne - body
joint pain / stiffness
weak nails that break or tear easily
bloating (frequently, more than once a week)
gas (frequently, more than once a week)
constipation (going #2 less than once a day)
hard to pass stool
pellet or pebble like stool
phglem in back of throat
catch colds, flu, viruses easily/frequently (more than once a year)
yeast infections frequently (more than once a year)
PMS - breast tenderness, bloating, cramps, mood swings, etc. around menstrual cycle*
period issues* (too long, too short, not coming on time, very heavy, etc. )
have you ever had mono at any point in your life?
have you taken antibiotics in the last 6 months?
have you taken antibiotics in the last year?
gastrointestinal issue/ disease*
cardiovascular disease or condition*
diagnosis of other disease or condition*
If you checked the box for any of the starred items above, please elaborate. (Write n/a if not applicable).
If you are desiring weight loss, what is your desired weight?
Please describe your relationship with food and your body as it is right now. What exactly are you struggling with?
What is your biggest obstacle(s) in reaching your health and wellness goals?
What is getting in your way?
How does feeling bad about your body or struggling with weight affecting you in your life?
Be specific. How does it affect your relationships. confidence, money, career, etc.
What do you need the most help with now? (Check all that apply)
Skin Problems (acne, pre-mature aging, etc.)
Lack of Energy
Education on What to Eat
How to Cook
Eating at Night
What have you done in the past to lose weight, or address the above issues?
Briefly describe your current daily eating habits. Do you follow a certain style of eating (Dairy-free, gluten-free, paleo, vegan, etc.) Do you avoid certain foods? Which foods do you eat a lot of?
If you take any supplements or medications on the regular, please list them here.
Check all the factors that apply to your current lifestyle and eating habits:
Erratic eating pattern
Eat too much
Late night eating
Dislike healthy food
Eat more than 50% meals away from home
Non-availability of healthy foods
Do not plan meals or menus
Reliance on convenience items
Poor snack choices
Significant other or family members don’t like healthy foods
Significant other or family members have special dietary needs or food preferences
Love to eat
Eat because I have to
Have a negative relationship to food
Struggle with eating issues
Emotional eater (eat when sad, lonely depressed, bored)
Eat too much under stress
Eat too little under stress
Don’t care to cook
Eating in the middle of the night
Confused about nutrition advice
Fatty/greasy food cravings
How did you find out about my program?
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