health history form & questionnaire

Please be as honest and detailed as you can. Your information will remain confidential between you and your Health Coach. There are no wrong answers. Once you hit submit I will get back to you via email.

Health History Form

Name *

First

Last

Email *

Phone

Age *

Height *

Current Weight *

Weight 6 months ago *

Weight a year ago *

Would you like your weight to be different? If yes, what is your goal weight? *

Relationship Status *

Where Do you Live? *

Do You have Children? If yes, how many? *

Occupation *

How Many Hours per Week do You work? *

What are Your Main Health Concerns? *

Do you have any other concerns or health goals? *

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

Any current or previous serious illnesses, hospitalizations, or injuries? *

How is/was your mother’s health? *

How is/was your father’s health? *

How is your sleep? *

How many hours of sleep do you get per night? *

Do you wake up during the night? If so, why? *

Any pain, stiffness, or swelling? *

Any constipation, diarrhea, or gas? *

Any allergies or sensitivities? *

to food or medication

How would you describe your daily stress?: *

What things, if any are you doing for self care?: *

yoga, meditation, exercise, journaling, anything that makes you feel better aka Me time

List all supplements or medications: *

Are you involved with any healers, helpers, or therapies? *

Chiropractors, massage, acupuncture, etc

What role do sports and exercise play in your life? *

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

Do you cook? If yes, What percentage of your food is home-cooked? *

Where does your non-home-cooked food come from? *

What foods did you eat often as a child? *

Give examples for breakfast, lunch, dinner, snacks, and drinks.

What foods do you typically eat these days? *

Give examples for breakfast, lunch, dinner, snacks, and drinks.

How much water do you drink per day? *

Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions *

What is the most important thing you should change about your diet to improve your health? *

Please rate these areas of life on a scale of 1-10 (1 being the worst and 10 being the best)

How would you rate your relationship or satisfaction with finances in your life

Selected Value: 0

How would you rate your relationship or satisfaction with spirituality in your life:

Selected Value: 0

How would you rate your relationship or satisfaction with your career in your life

Selected Value: 0

How would you rate your relationship or satisfaction with your marriage/significant other

Selected Value: 0

How would you rate your relationship or satisfaction with your social life

Selected Value: 0

How would you rate your relationship or satisfaction with your children (if you have any)

Selected Value: 0

How would you rate your relationship or satisfaction with your sex life

Selected Value: 0

How would you rate your relationship or satisfaction with your meal prep

Selected Value: 0

How would you rate your energy level after lunch time

Selected Value: 0

How would you rate your satisfaction with your immune system (do you get sick often)

Selected Value: 0

How would you rate your overall knowledge with health/nutrition

Selected Value: 0

How would you rate your support system from family / friends

Selected Value: 0

How would you rate your work related stress

Selected Value: 0

How would you rate your family related stress

Selected Value: 0

How would you rate your level of self care (me time)

Selected Value: 0

How committed are you to making changes to your health and lifestyle

Selected Value: 0

Is there anything else you would like to share?

Taking the First Step Towards Improving Your Health

Please rate these areas of life on a scale of 1-10 (1 being the worst and 10 being the best)

QUICK LINKS

OUR LOCATION