Health History
All of your information will remain confidential between you and the Health Coach.
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TODAYS DATE
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Name
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Your answer
Email
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Your answer
Phone
Your answer
Age / Birthdate
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Your answer
Current Weight
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Your answer
Would you like your weight to be different? If so, what?
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Your answer
Please list your main health concerns
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Your answer
Other concerns and/or goals?
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Your answer
At what point in your life did you feel best?
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Your answer
Any serious illnesses/hospitalizations/injuries?
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Your answer
How is your sleep? How many hours?
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Your answer
Allergies or sensitivities? Please explain.
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Your answer
Are your periods regular? How many days is your flow? Any pain?
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Your answer
Reached or approaching menopause? Please explain.
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Your answer
Do you take any supplements or medications? Please list
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Your answer
Any healers, helpers, or therapies with which you are involved? Please list.
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Your answer
Do you exercise? If so how many days a week?How long?
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Your answer
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
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Your answer
Do you crave sugar, coffee, cigarettes, or have any major addictions?
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Your answer
The most important thing I should do to improve my health is...
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Your answer
Anything else you would like to share?
Your answer
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