Health Questionnaire
Welcome to the Health History form.

If you are like most people, I imagine there are specific goals you have for your health and your life. I also imagine there are challenges or barriers to overcome in the quest to be healthier and happier. This form will help us discuss your goals, concerns, and general health background.

Once you complete this form, I will reach out to schedule our free introductory session. In this meeting, we will discuss your Health History, and get to know each other a bit more. I will also explain a lot more about how my health coaching program works. I like to think of this call as a Chemistry Session, we can figure out if our personalities mesh well, and if my coaching services meet your goals and needs.

*All your information, in this form and all conversations, will remain confidential.

GENERAL INFO
Name: *
Your answer
Age: *
Your answer
Email: *
Your answer
Cell Phone Number: *
Your answer
Height: *
Your answer
Current Weight (in lbs): *
Your answer
Would you like your weight to be different? If so, how?
Your answer
PERSONAL
Tell me about your life - where do you live? Married, kids? What do you do for a living? What are your hobbies? Help me get to know you and your life... *
Your answer
What do you most hope to get from a coach? *
Your answer
Have you hired a coach before? If so, how was it?
GENERAL HEALTH
What are your main health goals? What are your main health concerns? *
Your answer
Any current or previous serious illnesses, hospitalizations, or injuries? *
Your answer
List all supplements or medications: *
Your answer
Tell me about your sleep - How many hours do you sleep per night? How is it? *
Your answer
FOOD
Do you cook? What percentage of your food is home cooked? Where does your non-home-cooked food come from? *
Your answer
What food do you typically eat? List a few for these 5 categories - breakfast, lunch, dinner, snacks, and liquids: *
Your answer
What is the most important thing you should change about your diet to improve your health? *
Your answer
ADDITIONAL COMMENTS
Is there anything else you would like to share?
Your answer
AVAILABILITY
I will reach out via email or phone and schedule our free introductory session. It will be in-person if possible, or via Webcam (FaceTime, Google Hangout, or Skpye) or phone call.
What are the best days and times for us to do our 45 minute introductory session? *
Your answer
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