Health History
All of your information will remain confidential between you and the Health Coach.
TODAYS DATE *
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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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