Health History Questionnaire
Complete this form for a FREE Health History Session with Jamie Sossamon, Holistic Health Coach.
This form should take approximately 15 minutes to fill out.
Email address *
PERSONAL INFORMATION
First and Last Name *
Your answer
How often do you check email?
Your answer
Phone: Best number for our telephone session
Your answer
What date and time would you prefer our session to be on? There is no guarantee of this time, so please list at least 3 days and times you are available.
Your answer
Age
Your answer
Height
Your answer
Birth date
MM
/
DD
/
YYYY
Place of Birth
Your answer
Current Weight
Your answer
Weight six months ago
Your answer
Weight one year ago
Your answer
Would you like your weight to be different?
If so, what would be your desired weight?
Your answer
SOCIAL INFORMATION
Relationship status
Your answer
Where do you currently live?
Your answer
Do you have any children?
Do you have pets?
What is your occupation?
Your answer
How many hours do you work per week?
Your answer
HEALTH INFORMATION
What are your main health concerns?
Your answer
Do you have other concerns and/or goals?
Your answer
At what point in your life did you feel your best?
Your answer
Have you had any serious illnesses, hospitalizations and/or injuries?
Your answer
How is/was the health of your mother?
How is/was the health of your father?
What is your ancestry/heritage?
Your answer
What blood type are you?
Your answer
How is your sleep?
How many hours of sleep do you get per night?
Your answer
Do you wake up at night?
If so, why do you wake up at night?
Your answer
Do you have any pain, stiffness, and/or swelling?
Do you have constipation, diarrhea, and/or gas?
Do you have any allergies or sensitivities? Please explain:
Your answer
WOMEN'S HEALTH ONLY
Are your periods regular?
How many days is your flow?
Your answer
How frequent?
Your answer
Is your menstrual cycle painful or symptomatic? Please explain:
Your answer
Have you reached or are you approaching menopause? Please explain:
Your answer
Birth control history
Your answer
Do you experience yeast infections or urinary tract infections? Please explain:
Your answer
MEDICAL INFORMATION
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
What role do sports and exercise play in your life?
Your answer
FOOD INFORMATION
What foods did you eat often as a child?
Your answer
What is your food like these days?
Your answer
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Your answer
Do you cook?
What percentage of your food is home-cooked?
Your answer
Where do you get the rest from?
Your answer
Do you crave sugar, coffee, cigarettes, or have any major addictions?
Your answer
The most important thing I should do to improve my health is:
Your answer
ADDITIONAL COMMENTS
Anything else you would like to share with Jamie?
Your answer
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