Health History Download the Health History Form here >> Or fill out the form below: Health History Please write or print clearly. All of your information will remain confidential between you and the Health Coach.PERSONAL INFORMATIONName* First Last Email* How often do you check email?Home Phone*Work Phone*Mobile Phone*Age*Height*Birthdate*Place of Birth*Current Weight*Weight Six Months Ago*Weight One Year Ago*Would you like your weight to be different?* Yes No What would you like your weight to be?*SOCIAL INFORMATIONRelationship status*SingleIn a relationshipEngagedMarriedIt’s complicatedWidowedSeparatedDivorcedIn a civil unionIn a domestic partnershipWhere do you currently live?*How many children do you have?*How many pets do you have?*Occupation*How many hours of work per week?*HEALTH INFORMATIONPlease list your main health concerns*Other concerns and/or goals?*At what point in your life did you feel best?*Any serious illnesses/hospitalizations/injuries?*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 of sleep do you get?*Do you wake up at night? Yes No Why?*Any pain, stiffness, or swelling?*Constipation/Diarrhea/Gas?Allergies or sensitivities?* Yes No Please explain why you answered yes to allergies or sensitivities*Allergies or sensitivitiesAre your periods regular?* Yes No How many days is your flow?*How frequent?*Painful or symptomatic periods?* Yes No Please explain why your periods are painful or symptomatic.*Reached or approaching menopause?* Yes No Please explain your affirmative answer as to reached or approaching menopause.*Birth control history:*Do you experience yeast infections or urinary tract infections?* Yes No Please explain your experience with yeast infections or urinary tract infections.*MEDICAL INFORMATIONDo you take any supplements or medications?* Yes No Please list supplements or medications you take.*Any healers, helpers, or therapies with which you are involved?* Yes No Please list healers, helpers, or therapies with which you are involved.*What role do sports and exercise play in your life?*FOOD INFORMATIONWhat foods did you eat often as a child? Breakfast*Lunch*Dinner*Snacks*Liquids*What is your food like these days? Breakfast*Lunch*Dinner*Snacks*Liquids*Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?* Yes No Maybe Do you cook?* Yes No What percentage of your food is home-cooked?*Where do you get the rest from?*Do you crave sugar, coffee, cigarettes, or have any major addictions?*The most important thing I should do to improve my health is*ADDITIONAL COMMENTSAnything else you would like to share?*NameThis field is for validation purposes and should be left unchanged. Δ