Individual Health Form

Personalized Health Form

* Any and all information will be kept private between you and your Health Coach. Feel free to skip any information that does not specifically pertain to you or your health needs*

Name *

First

Last

GENDER *

Email *

How often do you check email? *

Home phone *

Work Phone *

Mobile Phone *

Age *

Height *

Birthdate (MM/DD/YYYY) *

Place of birth *

Current weight *

Weight 6 months ago *

Weight 1 year ago (can be estimate) *

Would you like your weight to be different? *

If so, how? *

SOCIAL INFORMATION

Relationship Status *

Where do you currently live? *

Children? *

Pets? *

Occupation *

Hours of work per week? *

HEALTH INFORMATION

Please list your main health concerns *

Other concerns and/or goals? *

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

Any serious hospitalizations or injuries? *

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

How is/was the health of your mother? *

How is/was the health of your father? *

What is your ancestry? *

What blood type are you? *

How is your sleep? *

How many hours? *

Do you wake up at night? If so, why? *

Any pain, stiffness, or swelling? *

Constipation, Diarrhea, or gas? *

Allergies or Sensitivities? *

MEDICAL INFORMATION

Do you take any supplements or medications? Please list *

Any healers, helpers, or therapies with which you are involved? Please list *

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

FOOD INFORMATION

Are there any staple foods you remember eating as a child? *

Now at your current age, what do you have for Breakfast? *

Lunch *

Dinner *

Snacks *

Liquids *

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

Do you cook? *

What percentage of your food is home-cooked? *

Do you have any addictions? Ex. Sugar, Coffee, Cigarettes, drugs, etc? *

The most important thing you would like to do to improve your health is? *

QUESTIONS SPECIFIC TO INDIVIDUALS WHO EXPERIENCE MENSTRATION.

* The following questions are specific to individuals who experience menstration (monthly periods). Any and all information provided will remain private between you and your health coach. Please SKIP if this does not apply to you*

Are your periods regular? *

How many days is your flow? *

How frequent? *

Painful or Symptomatic? *

Reached or approaching Menopause? Please explain *

Birth Control History *

Do you experience any yeast infections or UTIs? Please explain *

ANY ADDITIONAL QUESTIONS OR COMMENTS?

Comment *

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