Confidential Health History
Stratosphere Health Coaching
Name:
Full Address:
Email:
How often do you check email?
Telephone
Work:
Home:
Cell:
Age:
Height:
Date of Birth:
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Place of Birth:
Current Weight:
Weight 6 months ago:
One year ago:
Would you like your weight to be different?
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If so, what?
Relationship status:
Children?
Occupation:
Hours of work per week:
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