Health History Questionnaire
Please fill out all of the questions as completely as possible prior to our initial call.
Full Name
Your answer
Email Address
Your answer
Location/Timezone
Example: New York USA / ET
Your answer
Phone or Skype if outside US
Your answer
Occupation
Your answer
Family / living situation? (Live alone? Partner? Married? Have kids? How many?)
Your answer
Height
Your answer
Weight
Your answer
List your main concerns or goals which have prompted you to seek out health coaching.
Your answer
Do you experience any of the following?
Required
If you checked the box for any of the starred items above, please elaborate. (Write n/a if not applicable).
Your answer
If you are desiring weight loss, what is your desired weight?
Your answer
Please describe your relationship with food and your body as it is right now. What exactly are you struggling with?
Your answer
What is your biggest obstacle(s) in reaching your health and wellness goals?
What is getting in your way?
Your answer
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.
Your answer
What do you need the most help with now? (Check all that apply)
Required
What have you done in the past to lose weight, or address the above issues?
Your answer
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?
Your answer
If you take any supplements or medications on the regular, please list them here.
Your answer
Check all the factors that apply to your current lifestyle and eating habits:
Required
How did you find out about my program?
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