Health History

All of your information will remain confidential between you and the Health Coach.

TODAYS DATE *

YYYY

Name *

Your answer

Email *

Your answer

Phone

Your answer

Age / Birthdate *

Your answer

Current Weight *

Your answer

Would you like your weight to be different? If so, what? *

Your answer

Please list your main health concerns *

Your answer

Other concerns and/or goals? *

Your answer

At what point in your life did you feel best? *

Your answer

Any serious illnesses/hospitalizations/injuries? *

Your answer

How is your sleep? How many hours? *

Your answer

Allergies or sensitivities? Please explain. *

Your answer

Are your periods regular? How many days is your flow? Any pain? *

Your answer

Reached or approaching menopause? Please explain. *

Your answer

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

Do you exercise? If so how many days a week?How long? *

Your answer

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? *

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

Anything else you would like to share?

Your answer

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