Health History
Please fill-out the Health History to the best of your ability. All of this information will remain confidential between you and the health coach.
Email address *
First Name *
Your answer
Last Name *
Your answer
Email Address *
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Phone *
Your answer
Age
Your answer
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? If so, what?
Your answer
Relationship Status
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Where do you currently live?
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Children
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Pets
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Occupation/Hours worked per week
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Please list your health concerns
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Other concerns or goals?
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At what point in your life did you FEEL best?
Your answer
Any serious illnesses/hospitalizations/illness
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How is/was the health of your mother?
Your answer
How is/was the health of your father?
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What is your ancestry?
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What blood type are you?
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How is your sleep? How many hours do you get each night and do you wake up during the night?
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Any pain, stiffness or swelling?
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Constipation or digestive issues?
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Allergies or sensitivities? Please explain
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Do you take any medications or supplements? Please list:
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Any healers, helpers, or therapies in which you are involved?
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What role does exercise and sports play in your life?
Your answer
What food did you eat as a child for breakfast/lunch/dinner?
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What is your food like these days for breakfast/lunch/dinner/snacks?
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Will family and/or friends be supportive of your desire to make food and lifestyle changes?
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Do you cook?
Where do you get the rest of your food from?
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Do you have any major cravings or addictions?
The most important thing I should change about my diet to improve my health is....
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Additional Comments/Anything else you would like to share:
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