Health & Lifestyle Intake Form
All of your information will remain confidential between you and your coach.
Email address *
PERSONAL INFORMATION
First Name: *
Your answer
Last Name: *
Your answer
Phone Number: *
Your answer
Birthdate:
MM
/
DD
/
YYYY
SOCIAL INFORMATION
Where do you currently live?
Your answer
Where were you born?
Your answer
Relationship status:
Your answer
Children:
Your answer
Pets:
Your answer
Occupation:
Your answer
Hours of work per week?
Your answer
HEALTH INFORMATION
Age:
Your answer
Height:
Your answer
Current weight:
Your answer
Weight 6 months ago:
Your answer
Weight 1 year ago:
Your answer
Would you like your weight to be different? If so, what?
Your answer
Please list your main health concerns:
Your answer
Any serious illnesses/hospitalizations/injuries?:
Your answer
What role do sports and exercise play in your life?
Your answer
How is/was the health of your mother?
Your answer
How is/was the health of your father?
Your answer
What is your ancestry?
Your answer
How is your sleep? How many hours? Do you wake up at night? Why?
Your answer
Any pain, stiffness or swelling?
Your answer
Constipation/Diarrhea/Gas?
Your answer
Allergies or sensitivities? Please explain:
Your answer
Do you take any supplements or medications? Please list:
Your answer
Any healers, helpers or therapies with which you are involved? Please list:
Your answer
WOMEN'S HEALTH INFORMATION
Complete only if female anatomy.
Are your periods regular? How frequent?
Your answer
How many days is your flow?
Your answer
Painful or symptomatic? Please explain:
Your answer
Reached or approaching menopause? Please explain:
Your answer
Birth control history:
Your answer
Do you experience yeast infections or urinary tract infections? Please explain:
Your answer
FOOD INFORMATION
What foods do you currently eat?
Breakfast:
Your answer
Lunch:
Your answer
Dinner:
Your answer
Snacks:
Your answer
Liquids:
Your answer
What was your diet like growing up?
Your answer
Do you cook? If so, what percentage of your food is home-cooked? Where do you get the rest from?
Your answer
LIFESTYLE INFORMATION
Do you crave sugar, coffee, cigarettes, alcohol, drugs or have any major addictions?
Your answer
The most important thing I should do to improve my health and life is:
Your answer
What are three primary things you MOST WANT to create/experience:
Your answer
What is your vision of who you want to be? How would your life be different if you fully stepped into being that person?
Your answer
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?:
Your answer
On a scale from 1-10, how ready are you to invest in changing?
ADDITIONAL INFORMATION
Anything else you would like to share?:
Your answer
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This form was created inside of Wellthie Life.