Soma Health History Form for Health Coaching with Kimberly Stewart
This form is confidential and will not be shared with any affiliates or persons outside of Soma Wellness
How did you hear about Soma and Kimberly's Health Coaching?
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First and Last Name
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Email
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Mobile Phone
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Age
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Height
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Birthdate
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Place of Birth
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Current Weight
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Weight 6 months ago
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Weight 1 year ago
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Would you like your weight to be different?
What is your desired weight?
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Relationship Status
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Where do you currently live?
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Do you have children? If so, how many?
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Do you have pets? What are their names?
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Where do you currently work? About How many hours a week do you work?
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Please list your main health concerns in order of importance:
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Do you have any other concerns and/or goals? Please list them as well:
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At what point in your life did you feel your best?
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Have you had any serious illnesses/hospitalizations/injuries? Please list:
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How is your sleep?
Do you wake up at night? If so, please list why:
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Do you experience any pain, stiffness, or swelling? Please explain:
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Do you experience any of the following on a regular basis?
Do you have any allergies? Check all that apply
What is your ancestry?
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How is/was your mother's health?
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How is/was your father's health?
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What is your blood type?
Are your periods regular?
How many days is your flow?
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How frequent?
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Are they painful or symptomatic? Please explain:
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Are you approaching menopause? Please explain:
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Are you currently on birth control? If so, what kind?
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What is your history with birth control?
(How long have you been on birth control? Have you been on birth control in the past? Provide any information regarding your relationship with any type of birth control.)
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Do you experience either or both of the following?
About how many bowel movements do you have on a daily basis?
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Describe any skin concerns you may have, if any.
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What supplements or medications do you currently take?
(Please list name and dosage)
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Do you currently see any healers, counselors or therapists?
Please choose what best describes your childhood health. Check more than one if it applies.
Please list foods and drinks you consumed as a child through high school.
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Have you had any dental work? Please list procedures or corrections.
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Please list foods and drinks you currently consume these days.
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Where does the majority of your food come from in a week?
Do you crave any of the following on a daily basis? Check all that apply.
Are there any foods that you despise? Please list out.
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How are you doing in the area of relationships in your life? (1 being not so well and 5 being excellent)
How are you doing in regards to Spirituality? (1 being not so well and 5 being excellent)
How satisfied are you with your career? (1 being not satisfied and 5 being your dream job)
How are you doing in the area of incorporating movement/exercise into your life? (1 being not so well and 5 being excellent)
If you had free time to do whatever you wanted, how would you spend it?
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Will family and friends be supportive of your desire to make any food and/or lifestyle changes?
What is the most important thing you feel you should do to improve your health today?
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On a scale from 1-10, how committed are you to making any changes necessary for your long term health?
(1 knowing you need change but not wanting to do what it takes and 10 being fully ready to do whatever it takes)
Use 3 adjectives to describe yourself.
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